Dr David Garly: And another big thing that people do often is chat to family members in the evening and a lot of people have quite strained family relationships and the evening is usually the conventional time for having these conversations, but it can put you into quite an agitated state of mind. So you obviously do need to have these conversations, but perhaps trying to restructure your day so you can do these earlier on means that you're not wound up when you're trying to get into bed.
Dr Rupy: Okay. So no conversations about finances or who's cooking Christmas dinner.
Dr David Garly: Absolutely, Christmas dinner, that should be enemy number one.
Dr Rupy: Okay.
Dr David Garly: We needed a washing machine the other day and I was in bed just browsing washing machines. It's just stressing me out.
Dr Rupy: Stressing me out.
Dr David Garly: So that is not something you should do in the run up to bed.
Dr Rupy: David, great to have you here. I thought we could start off this conversation by talking a bit about your background because not only are you a sleep expert, a general practitioner, but your medical career started off in respiratory medicine.
Dr David Garly: It did, yes. So I've worked in quite a few different areas but prior to general practice and prior to really getting into sleep, I was working in respiratory medicine. And actually it's through that field that I first got into sleep. Sleep as a specialty is often sort of divided up. It's not fully a specialty by itself in the UK, but it gets divided up depending on what particular sleep disorder you're dealing with. And actually there's a condition called obstructive sleep apnoea which tends to come under the respiratory team. And when I was working in these departments, I found it a really, really satisfying place to work. So there's large aspects of medicine, in respiratory particularly, where treatments haven't really kept up with the diagnosis. There's conditions that you're often left feeling that you could do more for. But sleep apnoea is a really big exception to that, that if you have someone who hasn't slept properly for what could be a decade and then you get them on treatment, there's a really effective treatment called CPAP. You get them on this treatment, it could even be two days later that they really are like a new person. We had someone feedback to us who said they're normally asleep by about 8pm, but it's 10pm and they'd read about 200 pages of their book. So it's really, it's really satisfying place to work. And so now I've since moved to general practice where I see quite a variety of sleep disorders there as well and then also through the better sleep clinic, we deal predominantly with sleep apnoea and insomnia.
Dr Rupy: Got you. And obstructive sleep apnoea, what actually causes that? Whilst we're on that thread right now.
Dr David Garly: Sleep apnoea is quite an unusual condition and it does need a bit of explaining. So this is a sleep disorder associated with snoring where your upper airway repeatedly closes as you sleep. So basically your upper airway is made of either hard structures, like the roof of your mouth, the bony bit in the roof of your mouth, or soft structures like the back of the throat and the base of the tongue. And the hard structures stay in place by themselves, but soft structures need muscles to keep them in place. And the issue is that as you fall asleep, your these upper airway muscles relax and so your airway just gradually narrows in on itself. And it narrows in and actually it can, it can close. So when it's slightly narrow, you get turbulent air flow and this causes the soft structures to vibrate, which you hear as snoring. But if it keeps getting narrower, it can actually close. Which your body can only tolerate for a certain period of time, after which it actually has to pull you back to a lighter state of sleep or even completely awake so that you can pull open your airway and start breathing again. So you never fall into that deep restorative state of sleep that you need to feel refreshed in the morning because whenever you do, your airway closes, you stop breathing and your body has to wake you up.
Dr Rupy: So there's two big issues there from that description. There's the issue with the poor sleep, so you're not actually getting into those deep stages. Then also you're spending sometimes quite significantly a lot of that time in a hypoxic state. So you're not literally oxygenating yourself during that.
Dr David Garly: You absolutely are. You absolutely are. And there's a scoring system really with with sleep apnoea. And it's called the AHI, which is the number of times you stop breathing for at least 10 seconds. And so if you have an AHI of of 60, that's that's one time a minute. But you can get AHIs of 120, which means at least 20 seconds in every minute, you're not breathing. You have a closed airway and you do this thing, it's like seesawing, like your body's trying to pull air in. So you get these big pressure swings in your chest, you're hypoxic. And this is why, you can imagine after a decade of this, this is why people are so sick. So it's not just the fact that they haven't slept well and they've got really poor concentration, really poor memory, often quite depressed. It also means that you're at significant risk of cardiovascular disease, which is another big issue with sleep apnoea.
Dr Rupy: Huge. And am I right in thinking that obstructive sleep apnoea is more prevalent in people who are of a higher weight?
Dr David Garly: Yeah, so there's two key risk factors with sleep apnoea. Um, weight is one and age is the other. But what we see with our clinic is that there's an increasing number of people who who come through who are actually quite young and actually quite normal BMI. And a lot of that is just the shape of your airway. If you just by virtue of your anatomy, if when you lay on your back, your airway just gets narrower, you're just at high risk. So even being normal BMI and and young doesn't mean that you can't get it. And the reason these people come through, I think really is just increased awareness. There's a really difficult stat to to kind of cope with if you work with sleep and that is that 85% of people with obstructive sleep apnoea don't know they have it.
Dr Rupy: Wow.
Dr David Garly: So there's an ocean of people there who who don't know they have it. And hopefully with awareness, people are actually starting to come through now.
Dr Rupy: Yeah, yeah. And you mentioned the the hard roof of the of the mouth, the hard palate, and then you've also got these soft structures. And you mentioned muscle. And when most people think about muscles, they think about training the muscles to be more efficient, hypertrophy, all the rest of it. Is that a different type of muscle that we have at the back of our mouths?
Dr David Garly: Yeah, so there's different, there's different muscles that that support the soft structure of the airway. There's one that works as a bit of a sling here in your in your jaw called, I think it's genioglossus. And it's not really a muscle that's that easy to train. There are actually some relatively new tech that can actually train it in a similar way to a TENS machine. You know, back in the 90s, there was always TV adverts where it'd be someone with a six pack with, yeah, so it's like that, but kind of under here. So there are different ways you can do it. It's not something that we've been so involved with, but there is some evidence for this working with mild sleep apnoea and some types of snoring.
Dr Rupy: Wow. Wow. And and so in terms of outside of the TENS machine, are there any exercises that people can do with their tongue or there's there's something going viral right now called mewing, which is all about the structure of the face and and apparently it's how all these Hollywood actors are getting like jaw lines that are super chiselled. Yeah. I'm again, I'm not too sure about the evidence base for those.
Dr David Garly: Well, in fact, there is, there is an evidence base for something quite similar. And it's actually playing the didgeridoo. I don't know if you
Dr Rupy: Really?
Dr David Garly: Yeah, so didgeridoo, I don't know how much you know about this, but circular breathing.
Dr Rupy: My wife's Australian, so
Dr David Garly: Oh right, okay. Well, she'll know all about it then. Yeah. So it's called circular breathing. So basically you want to bring air into your lungs and you breathe out with your diaphragm until you're almost empty. But then you fill your mouth up with air and push it through with your throat while you then inhale again. So that, that's quite a difficult process to coordinate. And it usually leads to, you know, some hypertrophy or just reducing the fatigability of these these muscles. And there is some evidence, it was a study I think in Switzerland that looked at the impact on mild snoring and mild sleep apnoea. What was interesting actually is that they looked at the improvement in sleep both in the people doing the didgeridooing and and their bed partners. So because they snored less, actually their bed partners also slept better. So which is interesting.
Dr Rupy: That makes a lot of sense.
Dr David Garly: Yeah, yeah, yeah.
Dr Rupy: And you've probably heard about mouth taping where people are taping their mouths and breathing in through their nose. And you know, I'm not too sure whether that's being used as a treatment for snoring or obstructive sleep apnoea, but are there any benefits of doing that for general health that you're aware of?
Dr David Garly: I think mouth taping is is a difficult one to talk about because I think people do it, you know, in different ways and for different reasons. So it's not like there's a universally accepted way of doing it. Colloquially, you do hear about people reporting a health benefit. However, I think it's difficult to pick apart because if you're going to do mouth taping at night, it's unlikely that this is the only way that you're going to be trying to affect your health, that this is probably going to be coming down the line from someone who's probably quite committed about improving their health. And while they might feel benefits, I think it's difficult to attribute that purely to to mouth taping. Certainly, if you try and work purely on evidence base, then, you know, it's a difficult one to to kind of recommend at the moment. But we would certainly keep an open mind when, you know, data comes through.
Dr Rupy: Yeah. So it's one of those lower order activities rather than at the top of your list when it comes to improving people's sleep.
Dr David Garly: Yeah, it's not, it's not one and I think for sleep apnoea is one that people would find quite challenging. I, you know, I think having your mouth closed because it is often, it is based on resistance to airflow. And if you close your mouth, I think there might be certain anatomical types that may benefit, but it's not something that we would, we would recommend at the moment.
Dr Rupy: Got you. And and in terms of snoring in general, how do people differentiate between my partner or me, I'm just a loud snorer versus I've actually got a condition that requires treatment and potentially even CPAP. And you mentioned CPAP, maybe we should tell the listeners what that means.
Dr David Garly: Yeah, absolutely. Well, let's let's start with with CPAP. So it stands for continuous positive airway pressure. And basically this is a box that sits usually on your bedside table and there's a tube that blows air at a low pressure to a mask that sits either over your nose or over your mouth and nose. And it's a low pressure, but it just holds the airway open from the inside. So rather than this issue where your airway is continually collapsing, there's just a light pressure just holds it open. And you might think that this is quite an unusual treatment and in a way it is. But you can almost use this treatment diagnostically that if someone really hasn't slept properly for a decade, you stick them on the machine. There's often a bit of teething, but if you find at week one that they feel like a new person, that, you know, this treatment has revolutionised their health, then you can say this person had sleep apnoea. If they just had more straightforward snoring, they wouldn't tolerate the machine because they're not getting any of that daytime benefit.
Dr Rupy: Right, right. Okay. And in terms of other metrics that we could look at, maybe blood work or arterial bloods, are there any other clues in in someone that could point towards sleep apnoea before putting the CPAP on and then trialling out and seeing how they they feel?
Dr David Garly: Absolutely. So in terms of the nighttime symptoms, you would usually get snoring, but what you also get is once the airway has closed, you would expect there to be pauses in breathing. So often you'll have a bed partner that says they're always stopping breathing and I can't sleep because I don't know whether they're going to start breathing again. So you would expect that. And often as the airway opens, it starts, your breathing starts again with a snort or gasp. So these are the sort of the three nighttime symptoms. But then because you're not getting good quality sleep, even if you sleep for something like 10 hours, it's really poor quality and it's really fragmented. So you frequently wake up feeling unrefreshed. You might wake up with a headache. You are falling asleep throughout the day, falling asleep in meetings. And the big hazard of course is falling asleep when you're driving, which we don't want that. And so if you're getting these significant symptoms of daytime sleepiness, then that would really make us think that that this could be sleep apnoea.
Dr Rupy: Okay. So if I'm just a loud snorer at night, but I don't have the added symptoms of significant periods where my partner or let's say I'm I mean, I wear a sleep tracker. I have periods where I'm not breathing, or I feel completely refreshed during the day, that's pointing towards just being a loud snorer versus a condition like sleep apnoea. Have I got that right?
Dr David Garly: Yeah, certainly that that's pointing more to that. And indeed, there is a difference between sleep apnoea and what you call sleep apnoea syndrome. So you can even have some sleep apnoea with the stopping breathing, but for some people, it doesn't actually translate to significant daytime sleepiness. And again, it's the daytime symptoms that usually motivate people to seek help. And it's the daytime symptoms that actually enable you to to tolerate the CPAP. So there are some people who even if you, if you do a sleep test and it shows quite clear sleep apnoea, if they don't have any daytime symptoms, you would discuss with them if treatment is something that they want to pursue.
Dr Rupy: Got you.
Dr David Garly: So there is, there is a nuance to to this as well. So, I mean, this is something that we see in healthcare that that everyone is very much unique and individual and and sleep is exactly the same. And so it is difficult to get, you know, one single approach for for everyone. So it's something that that does need a bit of discussion.
Dr Rupy: Yeah. And let's say someone's listening to this and they think, gosh, that's my partner, you know, snoring really loudly, gaps in their breathing, doesn't feel refreshed at all. What would be their first point of call and what should they expect from, you know, if they are going to see their general practitioner, the next steps would would be?
Dr David Garly: Yeah, so certainly talk to the GP. There's a couple of scoring questionnaires that you'd probably run through. So one is called the Epworth sleepiness score. And this is a a series of questions about your likelihood to fall asleep in certain situations. So one of the questions is sitting reading a book, one is sitting quietly after lunch, one is being the passenger in a car. And I think we would all probably fall asleep in some of these situations. There's always some risk of it. I think that's quite normal. But if you're scoring quite highly, that suggests that you do have excessive daytime sleepiness. And then you have to start trying to work out why. There's another question called stop bang. And so this was actually designed by anaesthetists and that was looking at if you're going to go under a general anaesthetic, what is your risk of having sleep apnoea? Because this affects how they would manage your airway once you've finished the operation. And that asks questions like, do you have particularly loud snoring? Could someone hear you snoring if they were outside of your bedroom? Do you have episodes of stopping breathing? And they they go through other questions. I think neck circumference is on there as well, which is a bit of a risk factor. And so based on that, that would assign your risk. And and after a few other questions, you'd probably get referred on to a sleep clinic where they can carry out a sleep test and then a consultation to discuss what's actually going on with your sleep.
Dr Rupy: Got you. We've talked about sleep apnoea specifically as a cause for for people not getting enough sleep. But what are some of the warning signs that someone is getting poor sleep? And specifically, how many years in your mind do you think it could potentially cut someone's lifespan?
Dr David Garly: So the warning signs of getting poor sleep, if it's, if it's, I mean, it's difficult to say sort of definitively because sleep affects so many of our bodily processes. It's quite difficult to say specifically how it would affect you. But certainly daytime sleepiness is is one of the main symptoms. It is quite difficult to gauge if you slept well. There is something called sleep inertia. So if you, if your alarm clock goes off when it, when you're in a deep state of sleep, you feel like a zombie when you wake up. And people often think, I've not slept well because I feel like a zombie. But actually, once you're up, once you've had a coffee, you probably feel okay. But if routinely before lunchtime, you're wanting to go back to bed, that might suggest that you probably are not sleeping enough overnight. There are certain health conditions that you can develop. And again, all of these health conditions have a number of factors that can contribute towards them. But more and more, if you go to specialist health clinics, they do ask about sleep. So one big one is diabetes actually, that diabetes, there was a a study in the BMJ, which is a very famous medical journal that actually suggested that sleep should be seen as along with other more traditional risk factors for diabetes such as being overweight and various other things. So if you're developing, there's a kind of a notorious bunch of health conditions, then you really should look at your sleep and seeing whether this is a factor in in, you know, contributing to this.
Dr Rupy: Got you. Yeah. So you've got sleep inertia, daytime sleepiness, any other factors, any any other sort of like symptoms that people might be aware of during the day or look out for?
Dr David Garly: Yeah, so poor concentration is certainly one. And you know, to try and put all this together, if you think about how you feel if you've had to work a night shift or if you just haven't slept well, that you do feel quite zombie-like. You have trouble with your memory, you have trouble focusing. And low mood is actually a big thing as well, that you often feel quite flat the morning after not having slept quite well. But if you could imagine not sleeping properly for months or years, that's clearly going to have quite a significant impact on your mental health. And we know from quite good data actually that that if you're sleeping badly, you are much more likely to develop mental health conditions such as depression and anxiety and others as well.
Dr Rupy: Yeah. So you've got low mood, you've got poor concentration. And I guess the the interesting point you made about the risk of type two diabetes is the potential mechanism behind sleep and how that affects your ability to regulate blood sugar. I wonder if we could perhaps step back and talk a bit about why sleep is so important as a feature of everyone's 24 hours. But then when that goes awry, why it has an impact on things like mood, things like blood sugar regulation, cardiovascular disease. There's so many different avenues there we can sort of unpick. But maybe giving a broader picture of why sleep is so important first of all, and then why it has specific links with different conditions.
Dr David Garly: Yeah, so the the exact functions for sleep, there is still a bit of mystery surrounding this. But one aspect is clearly about physical rest and recuperation. And if you look at the secretion of growth hormone, the majority of this is actually released as you're asleep. So if you're missing out on sleep, you're missing out on physical growth and repair. Large parts of your immune system are actually protein-based in the form of antibodies. So if you're not sleeping, you're not necessarily regenerating your antibodies in the same way. So if you are sleeping less, you do sometimes find that you do get infections a bit more frequently than you would do otherwise. There's really good data on actually the role of sleep in memory, particularly moving things from short-term memory to long-term memory, memory consolidation, which actually happens with listening types of memory, which I think you might call declarative memory, but also about muscle memory. So about how this learning is carried out. So that'd be why if you're not sleeping that you won't remember particularly well. And then there's another particular state of sleep called REM, rapid eye movement sleep. And I would say of all areas of sleep, I'd say there's most mystery surrounding this and its exact role, but it appears to be due to or it takes place for emotional regulation. And you might know this is also your dreaming sleep. And it's again, there's so many things that aren't clear about this, but if ever you wondered why your dreams have such a high emotional content that you're normally being chased by something or there's some element of survival. But some people think that you're exposed to such high emotions in your REM state of sleep that it gives you an opportunity to try and moderate these emotions so that while you're awake, you're a bit more in control of your emotions. And so if you're not sleeping, then you're not going to be carrying out these aspects, these bodily processes. And this is why it has the impact on your health that it does. Another thing to mention is that when you're asleep, your heart rate is lower, your blood pressure is lower. And if you sleep for on average, it varies between people, but around eight hours a day, that's about a third of your day. So that's four months per year or around 30 years of your life, ish, then that's a huge amount of cardiovascular respite. And so if you're not sleeping, even if it's an hour or two hours shorter than you normally would do, over a lifetime, that means that you're spending much more of your time in a in a more stressed cardiovascular state. And you have increased expression of the the hormones that are associated with wake such as cortisol, which also has effects on blood sugar.
Dr Rupy: Yeah, yeah. That's a it's a nice way of thinking about it, all these different areas that sleep or good quality sleep can have an impact on. And I particularly like the, I guess that is that a hypothesis about REM sleep regarding sort of like practicing what it's like in your dream state to be chased by a lion or chased by your boss at work or whatever. So that when you're in the real world, you're a little bit more tolerant of it.
Dr David Garly: It's very much a hypothesis. Yeah. But I think that's what's good about sleep is that you've got emerging now really good data on impact of sleep on your health, evidence ways to help your sleep and get your sleeping better and have that impact on your quality of life. But right next to that, you've got this, there is no other word apart from mystery. But it's not common in medicine that you find these two, you know, evidence-based and mystery just pressed quite so close together. And I think that's one of the things that makes sleep a fantastic place to work that it's it's still got that enigmatic charm about it. But we'll see, there's a lot of data about now. I think it'll be five or 10 years until the dust has really settled on a lot of that research, but I think we'll start to find out more about what REM is and and why we do it.
Dr Rupy: Yeah. And I like the explanation around heart rate and blood pressure during sleep and why over a lifetime that gives you respite from your day-to-day. Because I've started being a little bit more fastidious about tracking what my heart rate is doing during the day and how many periods of stress I have during the day, which unfortunately is a lot. And I can only imagine what my blood pressure is doing as well during those periods of time. And so if the only point in your day is going to be when you're sleeping, when your blood pressure goes down, your heart rate goes down, and if you're disrupting that normal mechanism, you can understand why over a lifetime that increased level of blood pressure, the increased heart rate is going to be putting you at further risk because we already know what the impact of high blood pressure is on the cardiovascular system.
Dr David Garly: Yeah, absolutely. And arteries furring up, I mean, that's a a natural process, but it's just there are certain lifestyle features that just mean that happens just a bit quicker. And it's certainly not saying that if you sleep badly, you will have a heart attack. It's all just about your risk. And we just do what we can to help people lower their risk over a lifetime. And and increasingly sleep is being seen as a a relevant player here. For a long time, it's not really been on the agenda in quite the same way. And I think there's good reasons for that. I think when people want to make positive change in their life, sleep can be viewed as a bit more of a a passive thing. And if you want to make change, you perhaps gravitate towards active processes such as nutrition, such as exercise. Also, I think simply the fact that when you're asleep, you are unconscious. You don't really recall that process. So if you if you to think about a day, if you think about yesterday or a day last week, you probably start your reflections about 7:00 or so in the morning when you wake up and then you finish them when you go to bed. And so it's understandable why sleep doesn't get into the psyche in quite the same way. If you cut health right back to its most fundamental structure, the three pillars of health, which are exercise, nutrition and sleep, you find exercise and nutrition get quite a lot of coverage. If you look at wellness programs or employee assistance programs or even policy, you find that sleep is not quite as represented as its other two partners. And that is changing and it's really important to to talk about that. It's important that we talk about that because one, sleep does have a huge impact on your health. But the other thing is that poor sleep can be fixed. And when you sleep better, you know, all these aspects of your life get better.
Dr Rupy: Yeah. I think it's a really good point you made about the active and passive processes. So when you change your diet or when you go to the gym, that's very much something that you feel is in within the locus of your control. I can do this, I can, you know, power my way through it. When it comes to things like sleep or reflective practices, journaling, emotional health, being reflective, mind wandering, all that kind of stuff, it's seen almost, I think, as a bit of a luxury and a bit of a, it's like you said, it's a passive, it seems to be more of a passive process. But as we'll go into a little bit later, you know, there are some active things that you can do to to be more proactive about improving one's sleep.
Dr David Garly: Yeah.
Dr Rupy: Before we get into improving sleep, why don't we talk about these these systems that control sleep? I think people have heard a lot of things around certain hormones, melatonin, adenosine, and the circadian rhythm. Maybe we should sort of anchor the listener as to what all these mean and and how they interact with each other.
Dr David Garly: Yeah. So yeah, so this is really about the control of sleep. And this is another really, I'm going to keep using the word enigmatic, but it is. Sleep is one of these things that we're often told is is so important. You can survive longer without food than you can without sleep. But unlike these other processes, sleep is actually outside of our voluntary control, which is unusual. And furthermore, the harder you try and sleep, the less likely it is to happen, which is just a a baffling aspect of sleep. And a lot of the frustrations that we come across in the sleep clinic are about people who are struggling to control their sleep. Either they can't sleep at night or they can't stop sleeping during the day. So we find it's really good to talk about the control of sleep. And there are broadly speaking two systems involved here. One is the adenosine system and one is the circadian rhythm. To start with adenosine, adenosine is a chemical that your body makes when you're awake. It accumulates, the more adenosine you have, the more sleepy you feel. And the only thing that can get rid of adenosine is sleep. And so this basically is the idea that the longer you're awake, the more sleepy you feel. But you can explore this in a bit more detail if you think about what happens if you pull an all nighter or if you do a night shift, which I'm sure you're familiar with from from times in hospital. But if you stay up all day, it's normal until you cross your bedtime. When you go past your bedtime, you'll start to feel a bit tired, but you can kind of power through. But anyone who's done a night shift will tell you that the most difficult time to stay awake is probably about 3:00 or maybe 4:00 in the morning when your brain just seems to seize. You can't do anything. You feel freezing cold. But what's unusual is that when 8:00 a.m. rolls round or 9:00 a.m., you start to feel all right. You start to feel more awake. So you've been awake for longer, but you're starting to feel more awake. So you have more adenosine, but you're feeling more awake. So clearly there's another system at play and that is the circadian rhythm. And so this is this idea that your body runs with a natural internal rhythm. And one of the things that is running on this circadian basis is the control of wake and sleep. And the reason this has developed is because as humans, we are so reliant on light for our activities that we're primarily visual species. So we need light to do our activities. So we've evolved to be more active during daylight hours and sleep at night. And this entrains, it's called, our circadian rhythm. So it runs with its own momentum. But what's really interesting about the circadian rhythm is that this innate internal momentum runs for just longer than a day. So you think if it was based on light, it would be 24 hours, but it's actually more like 24.2. Yeah. So that means that you're constantly overrunning. And so your body has to keep pulling you back in line. And what actually pulls you back in line are what's called time givers. And the most important of these is light. And this is this is genius, I think, that this is a way that your internal body clock stays in sync with the external moving of the seasons. So otherwise what would happen is say in March, you might wake up at dawn, which is fine. But then in October, you'd find that you're waking up at something like 3:00 in the morning. So this is how you keep in track with the seasons, which is fantastic. So, yes, as I was saying, this entrains your circadian rhythm. And you have the two systems working. So circadian rhythm will will start to kick up at around 7:00 when you wake up. It'll make you feel more awake during the day. And then towards the evening, usually around a couple of hours before your normal bedtime, it will start to drop and you'll start to feel this strong urge to sleep because that will correspond to higher levels of adenosine.
Dr Rupy: Right. And adenosine, where where exactly is adenosine secreted from?
Dr David Garly: So adenosine, so there's a bit of mystery around adenosine as well. It used to be called substance S, which I think was a much better name. They've called it adenosine now. I think it's on a sort of a individual cellular level rather than, you know, from one one particular place. And adenosine, of course, exists in other forms as adenosine triphosphate, ATP, which is used a lot for metabolism for energy and so on. So, yeah, it's kind of a universal thing. Interestingly, adenosine is blocked by caffeine. So when you have a coffee, you find that actually blocks adenosine. So it does temporarily postpone tiredness. That's just another.
Dr Rupy: Are there any other things that block adenosine other than caffeine? Because I think I I now understand why I get that caffeine crash. And we were just saying before we jumped on the podcast how every year I do a coffee fast for 30 days to sort of rebalance my tolerance for caffeine. So, you know, I'm I'm less tolerant of those adenosine blocking effects. Are there any other things that block adenosine that you're aware of?
Dr David Garly: I suspect there are. I don't know specifically what would block adenosine. There are a number of other stimulants that you come across in day-to-day life. Nicotine would be the other big one. And certainly when we're talking about ways to sleep better, being mindful about both caffeine and nicotine are important. And caffeine you get in loads of things actually. So it's surprising. So certainly chocolate. Green tea is the other one that I think green tea gets mis-sold to a lot of people who are trying to cut down. Yeah. And the other one is actually decaf. Decaf is just less caf really rather than no caf. Yeah, which I didn't know for a long time.
Dr Rupy: I had a good chat with Dr. William Lee and he was talking to me about the biological reason as to why there's even caffeine in coffee and tea. And it's because it's nature's pesticide. And at certain times of the harvest when you're picking certain tea leaves or the coffee beans, there'll be varying levels of caffeine. So you can have the same exact bean, but it can have widely different caffeine levels depending on when it was picked and what time of the season. And it's just, yeah, fascinating because I've got no idea how much caffeine I'm consuming on a daily basis. And that could in that respect because I just have my coffee, I buy it from the same roaster, but it could be widely different.
Dr David Garly: I mean, that's another thing that's that's really interesting about when you're dealing with kind of raw, organically grown items is that they do vary. There is that variation that it's this isn't a lab created entity coffee. So that's interesting. I didn't know that about about the the season that you pick it.
Dr Rupy: Yeah, yeah, yeah, interesting. And in terms of circadian rhythm, can we purposely entrain it? So let's say I want to be a morning person and I mean, luckily I am. But a lot of people sort of are attracted to a lifestyle whereby you wake up first thing before most people wake up, let's say like 5:00 in the morning, and then you go to sleep early. Is that something that is innate within each individual and is genetically programmed or is it something that we can actually train ourselves to?
Dr David Garly: That's a really good question. And the term that you'll come across is your chronotype. And this broadly speaking is whether you're a morning lark or a night owl. And to an extent, that is a bit how you're born, is how you're made up. And that you do naturally have a preference about when you're when your best hours are. Though you absolutely can entrain that, though the extent to which you can do that does vary. If you expose yourself to ideally sunlight in around the first hour after waking, this will over time start to what you call, well, it will reinforce your circadian rhythm. But if the earlier you get exposed to sunlight, it's called phase shifting, so you can shift it back. But it does vary. Some people will get away with absolutely entraining it. And certainly if you're very committed to this over years, you'll probably find that you become a morning person. I can't imagine there's many bakers who've retired and went, you know, reverted back to being a an evening type. I think that's probably quite unlikely. So it can be done, but I think some people find that more of an uphill struggle than others.
Dr Rupy: Yeah. On the subject of training or phase shifting, maybe we should talk about jet lag here because I always get questions about jet lag. I'm I'm lucky that I get to go to Australia around once, twice every every two years, I'm at least in Australia for a good month or so because family are there, my wife's from Australia. What is jet lag and how can we improve our our tolerance of the crossing the time zones as best as possible?
Dr David Garly: That's a good question. So jet lag would fall into a category of circadian rhythm disorders. So circadian rhythm disorders are either intrinsic or extrinsic. So intrinsic are if you're an extreme morning lark or an extreme night owl, you find it's quite difficult to to kind of fit with society because you're your waking hours are in the middle of the night. So it's hard to fit in. But an extrinsic circadian rhythm disorder is a jet lag or the other one is shift work. That's when you have inside yourself, you have quite a strong and healthy circadian rhythm, but you've basically picked yourself up and put yourself in the wrong time zone. So for that reason, they are no longer synchronized. This is obviously more of an issue now with more air travel, but you you basically have to travel over most people would say two time zones really to to feel that effect. And and really if you could imagine flying from say London and flying either east or west. If you take east first, you're going to land and when you land, it's going to be later than your body thinks it is. And so the result is society there is going to want you to go to bed early. And I don't know if you've ever tried to go to bed early, but it's almost impossible. If you go into bed at 7:00, you're not going to sleep. But similarly, if you fly west, when you arrive, it feels earlier. But people actually tend to do better with that. It's just like trying to go to bed later. So you can, you can normally force yourself to stay awake easier than you can force yourself to go to sleep earlier. So that's how it works. In terms of how you can deal with that, it it can be really difficult. But there's there's two things really to say. One is that it's there's often two things going on when you arrive and you're tired. One is jet lag and the other one is traveler fatigue. So if anyone has gone on a eight or 10 hour bus even around the same country, you're absolutely knackered when you arrive. And so you've usually got two things going on. But with jet lag, there's two pronged approach. One is to try and adapt as soon as you can and be less tired. And then the other is to try and cope better with the tiredness because there's usually inevitably some tiredness. So you don't have to do one, you try and do both. So in terms of trying to adapt early, you can, depending on the direction that you're flying, do some partial pre-travel circadian adaptation. So you can try and basically get yourself into the destination time zone a little bit earlier. So if you wanted to phase shift and bring your bedtime earlier, a good way is something like a sunrise walk. So getting up early and going for a walk. So moderate exercise exposed to sunlight will actually over a couple of days probably just bring your bedtime naturally a little earlier, which might just offset the difficulties that you get on arrival. You can also adjust to the destination time zone as soon as you get on the airplane. And this is something that most airlines do anyway. I actually find it quite off putting if you get on a plane at, you know, at 8:00 p.m., they'll then put all the lights on. But I think what they're normally trying to do is encourage you to get into the destination time zone. And actually when you arrive, you really want to expose yourself to as many as of these circadian time givers as you can. So sunlight is the most important one. So as soon as you wake up, wake up at a conventional time, so 7:00 or 8:00 in the morning or whatever the destination time would be. And get out into sunlight in the first hour after waking. A bit of moderate exercise. And the third thing I would suggest is actually have your meals at conventional times as well. So really try to encourage yourself to have breakfast, to have lunch and have dinner at conventional times because this all feeds into this circadian physiology that you have and helps get you back in sync.
Dr Rupy: Got you. So let's use an example. I'm flying west from London to New York. What would be the best time to fly using that analogy? So if I'm leaving, I don't know, should I leave at 8:00 p.m. or 8:00 a.m. in terms of the best way to adjust my circadian rhythm?
Dr David Garly: That's a good question. So how long's the flight?
Dr Rupy: So let's say it's a six-hour flight and the time zone, we're crossing five time zones. So they're less five hours.
Dr David Garly: This this does sound a lot like a maths question.
Dr Rupy: I'm giving you GCSE maths question.
Dr David Garly: So we're leaving at 8:00 p.m. and it takes six hours.
Dr Rupy: Takes six hours.
Dr David Garly: 9, 10, 11, 12, 1, 2. So you would arrive at 2:00, but we're going back five hours, are we?
Dr Rupy: We're going back five hours, yeah.
Dr David Garly: So that basically means we arrive at 9:00 p.m. local.
Dr Rupy: Okay.
Dr David Garly: Which isn't too bad. So that's not too bad because of course you are going to have the traveler fatigue as well. So you're going to arrive knackered and you're probably going to want to sleep anyway. And so why fight it? So if you arrive at a conventional time, that probably would get you in sync. The only thing you have to bear in mind is if you want to adapt as soon as you can, you're going to have to be quite committed about getting out of bed at the right time. So a good alarm clock.
Dr Rupy: On that flight, I should be staying awake the entire time.
Dr David Garly: You should, yes, you should be. Yeah. So that's the that's the important thing as well. So resist the urge to to nap on the flight.
Dr Rupy: Yeah, okay. So no napping on the flight. I get there at 9:00 p.m. and I go to sleep straight away and I'm fastidious about waking up as early as possible when I'm in New York.
Dr David Garly: Fastidious is the word.
Dr Rupy: Yeah. Fastidious is the word. And getting that, getting that morning light at like, let's say 6:00 a.m. Let's say we're going in the middle of the spring. I'm not going to New York by anyway, but I think this is like a nice example.
Dr David Garly: It's a great city.
Dr Rupy: It's a great city, yeah. And so I'll get sunlight and then I'll eat my breakfast that I I usually do. I usually delay my breakfast to about 10, 10:00 in the morning, 11:00 in the morning. So I do that straight away. And apart from eating and sunlight, is there anything else that people should be aware of? Because my my personal issue whenever I travel is that my digestive system is all over the place. And I I guess it goes back to the circadian system whereby not just your sleep wake cycle, but every organ in your body is trained on a circadian rhythm. So, you know, when I usually go to the bathroom is going to be very different depending on where I am and what time of day it is if I've traveled.
Dr David Garly: Yeah, it it can cause, it can upset the apple cart. And you're absolutely right. There are, there's more data each year in circadian biology about how physiology, your your kind of biological processes are, more and more appear to work on a circadian basis. And yeah, I mean, this is another one of the things I think is really interesting about sleep. It's because so much of our processes are circadian, you know, even how your pancreas works is really related to the burning of a star millions of miles away. And again, this is where the science meets the kind of mystery of sleep that you do get left with this quite profound feeling of oneness with the universe that so much of what you think is actually quite a mundane process in your body relates to a star at the center of the solar system, which I think is really interesting.
Dr Rupy: Yeah, yeah, totally. And conversely, let's say I'm leaving New York at the same time at 8:00 p.m. So there's a six-hour flight. So if I'm using local time, that means I arrive at 2:00 in the morning, but we're going forward in time by five hours. So we actually arrive 7:00 a.m. London time. So you're arriving at 7:00 a.m., but your body thinks it's 2:00 in the morning.
Dr David Garly: Yeah.
Dr Rupy: And in that scenario, I guess you'd probably want to sleep on that flight and then just basically you're going to have to suck it up, I guess, aren't you?
Dr David Garly: I'm afraid so. Yeah, yeah. And just pick the activities that are easier to stay awake with. So, you know, sitting down and trying to do paperwork is probably a bad idea. But to be up and about, you know, if you have any tasks that are more physical, you know, on your feet, that's going to be much easier to do. Keep yourself out of bed. And then, you know, a relatively early bedtime, that is going to help you. You will find it difficult on the first day. I think you have to acknowledge that. But really it's about looking at how you cope over the next sort of three days, five days and trying to get you back into sync as quickly as you can.
Dr Rupy: Yeah. So I avoid what's known as red eyes for that reason because A, it's really hard to sleep on the plane. And B, even if you do fall asleep on the plane, the quality of your sleep is going to be disrupted. And when you get to your destination, you have to quickly sort of shuffle your circadian rhythm to activities that are, you know, going to align with everything. Whereas if you had the choice in that same scenario going New York to London, where your travel time is six hours and you're going ahead in time five hours, you'd want to leave at 8:00 a.m., I guess, because that way, all you need to do is stay awake on that flight and then go to sleep early at your destination.
Dr David Garly: Yeah, these people tend to find this easier. So staying up when you're tired is easier than falling asleep early when you're you're not tired. That's the sort of the general premise. But, you know, this you have to kind of accept that you will be you will be quite tired. And it's a good point said about trying to sleep on on the plane that it actually isn't usually particularly good quality sleep. And people often feel cheated or short changed when they arrive. They feel like I slept for the whole flight, but I'm still tired. And it's because there, you know, sleep is not just seen in terms of quantity, it is quality as well.
Dr Rupy: Yeah, totally. Okay, so let's let's use the same example. I'm not going to do any more math, don't worry. So we're we're back home, we're in London, we're trying to get to sleep. What are the things that you talk about, particularly in your clinic, the better sleep clinic? What are the things that you you tell people to to do to sort of encourage sleepiness and and get into rhythm?
Dr David Garly: Yeah. So this is an area that's usually called sleep hygiene. It's a term I really don't like because it gives you absolutely no idea about what it is. And you often have to spend half the time trying to explain the word to to patients. But really it's um, it's the good advice, the general advice on the routines and practices that encourage good sleep to get your mind and body into the right state for sleep and making your bedroom the best environment for sleeping in. Often people have come across it, but I think it often looks like a very arbitrary set of rules without any explanation behind it. I think it's much easier to see it in three categories. So one is scheduling, then preparation for sleep and then the bedroom. And so scheduling really comes back to the circadian rhythm. When you can't sleep at night, you often become quite focused on that aspect. But really, if you shift your focus to earlier in the day and look about how you can reinforce the wake phase of your circadian rhythm, then this makes the sleep phase come much more naturally at night. And in terms of how you strengthen your circadian rhythm, consistency is the most important thing. And really that's around your wake up time. So bedtime is there's much more flexibility about bedtime, but waking up, you really want that to be quite set in stone. So same time during the week and and if you have to vary it, no more than an hour at the weekend. So no long lie-ins. And so when you get that consistency, you'll find that that really is reflected in your circadian rhythm. Exposing yourself to sunlight, ideally in the first hour after waking, the best way is just to get outside. If you can't do that, you can sit next to a window. There are various lights you can buy, lamps and so on, which I think there is some evidence behind, but it's never going to be as good as just getting into the sunlight. And moderate exercise, ideally in the morning, these three things together really strengthen that circadian rhythm. So that is scheduling. And then in terms of preparation for sleep, so this is about getting your mind and your body into the right state for sleep. So starting with the body, this is someone to to kind of be mindful of is is caffeine. And again, it affects people in different ways. It blocks adenosine, so it postpones tiredness. So during the day, this is a helpful thing. But at night, you perhaps should be slightly more mindful. Also, what varies between people is the rate at which they eliminate caffeine from their body. And it tends to get a bit longer as you get older. Oh, it gets longer. Yeah, I believe so. Yeah, that, you know, you often you find you could get away with caffeine when you were younger, but when you get older, you find that this really is becoming the the final straw in disrupting your sleep. So, so just being mindful. And for me, for example, I can drink coffee. I can drink coffee almost up until bedtime and I'll sleep fine. But someone I work with won't have any after lunchtime. So it's really just knowing about how it affects you as an individual. And there's there's caffeine and then of course there's nicotine. So generally speaking, this isn't good for any aspect of your health. But certainly with sleep, it does promote wakefulness, which isn't helpful if you're trying to sleep. And in terms of getting your mind into the right state for sleep, it's worth having something like a wind down routine. And there's some really good practical advice on doing this. So you can actually set an alarm on your phone after which you don't do any more checking your email inbox, which is my big thing that if I check emails towards bedtime, it just turns my mind on and it stimulates my mind at a point when I really want to be bringing it down and trying to rest. And another big thing that people do often is chat to family members in the evening. A lot of people have quite strained family relationships and the evening is usually the conventional time for having these conversations, but it can put you into quite an agitated state of mind. So you obviously do need to have these conversations, but perhaps trying to restructure your day so you can do these earlier on means that you're not wound up when you're trying to get into bed.
Dr Rupy: Okay. So no conversations about finances or who's cooking Christmas dinner.
Dr David Garly: Absolutely, Christmas dinner, that should be enemy number one. We needed a washing machine the other day and I was in bed just browsing washing machines. It's just stressing me out. So that is not something you should do in the run up to bed.
Dr Rupy: Got you. Are there any other sort of strategies that you recommend, things like journaling, gratitude practices, mindfulness techniques?
Dr David Garly: So journaling is one that we use a lot in our clinic. And this is called different things. So we call it sleep journaling, other people call it constructive worry. But if you find that you're struggling to fall asleep because you have particular thoughts running around in your mind, or if you wake up in the night, it's quite common to do this. But if you can't get back to sleep because you're thinking of something, it's worth not trying to suppress this, but just acknowledging it. And what we would say practically is maybe two or three hours before you go to bed, so not right before you go to bed, is you sit down with a book, you know, it's the date and you write down the things that are on your mind. And you basically just think about them. You think about stuff that's been bothering you, you think about things that you have to do, deadlines that are coming up. And you just have a committed period of time when you think about these things because they do need thinking about. And then you put a time at the bottom the following day when you're going to think about this next. And this is going to be once you're up, once you're out of bed, this is going to be when you open up your book and think about things again. And then you can quite symbolically close the book. And this means that when the thoughts come up in your head later, and they will, you can just acknowledge the fact that you have these things to think about, but you're not going to think about them now when you're going to sleep. And I think that's a really powerful way at more compartmentalizing your worry. You can't not worry about things. And it's pointless when you say to people, don't worry. It's just not as simple as that. You have to worry, unfortunately, but it's just trying to do it at a point when you're not trying to sleep.
Dr Rupy: I'm going to use that because I struggle to compartmentalize a lot. And I've got a number of different pressures in different areas of my life, you know, there's family life, there's personal life, friends, there's business and there's a whole bunch of different threads in that. And sometimes that can all come to a head when I've got a moment to stop thinking in the evening when I'm going to bed and then suddenly you just get these spiraling thoughts and stuff. So having constructive, what did you call it? Constructive?
Dr David Garly: Constructive worry.
Dr Rupy: Constructive worry. I'm going to start using that. So it's just a a book on the side, is it? And then you just write down.
Dr David Garly: You can do it anywhere you want really, but yeah, I use a book if ever I do it and I do do it. Other people are much more happier you just doing it with their phone. Other people who perhaps aren't writers can just be disciplined enough to just think about it and go, I'm thinking about it now and I'm not thinking about it later. I think you can start with the book and then you'll find that you are just a bit more disciplined with your thoughts, you know, as you develop this as a skill. But it is a skill. And absolutely when you're laying in bed and because I think it's different when you're in work, this really encourages you to think about work things. When you're with friends and family, it encourages that theme of thought. But when you're in bed and there is nothing to prompt you or guide you, you get these thoughts just popping up. But if there's something that's really just recurrently bothering you, then suppressing thoughts doesn't work. But shuffling them to a different part of the day does.
Dr Rupy: What if I'm so knackered, I end up falling asleep and then for some reason, I have a micro awake in the middle of the night, go to the bathroom, whatever, and then my thoughts start spiraling. I'm like, oh, I've got to do that thing tomorrow. I've got to do this. Oh, I forgot about that thing that I've got to do next week. And then all of a sudden, you're wide awake and you're completely wired that I've had, I've been in that situation, many of my patients have been in that situation as well. What what do you say to that?
Dr David Garly: So this is really common in insomnia. So insomnia, you would categorize broadly as either being sleep onset when you can't fall asleep or maintenance that you can't stay asleep. And the two are clearly related. But if you can't sleep because you're getting, you know, you've woken up and then you suddenly get this thought or or for whatever reason, you're you're just you can't get back to sleep. We normally say something around 15 or 20 minutes, try to sleep, but if you can't, don't beat yourself up. But certainly don't lie in bed trying to sleep or or having these thoughts. You really should get up out of bed. And if you've if you live in the sort of place where you can get out of your bedroom and sit downstairs, that's ideal. But sitting usually in a in a comfortable chair away from the bed and finding a relaxing and distracting activity to take your mind off this. So people do different things. Reading a book is really common. And you want to pick, you want to pick an activity that is engaging enough that it stops you thinking about these random thoughts that are coming into your mind, but not so engaging that it actually activates your mind. You want it definitely in that sweet spot. People used to say read the phone directory. We don't, no one has a phone directory anymore. But you want something in that sweet spot. So you don't want to do a crossword, but neither do you want to do something that's just too boring and doesn't actually manage to take your mind off. So you want to do this activity until the urge to sleep comes back because it will come back. It's often quite wavelike that you've you've missed one wave, that's no problem. But just wait for the next one. Sit downstairs and then when you feel your eyelids are getting heavy, then go back up and get into bed. And that that works because one of the drivers of insomnia is actually when you damage the link between the bed meaning sleep. If you talk to someone who sleeps really well and you ask them, how do you sleep? They'll just go, I just sleep. There's nothing they do. They get into bed and their body knows and it's very much like Pavlov's dog with the story that, you know, you heard they heard the bell and they started salivating. So your body gets into bed and should know it's time to sleep. You know, your adenosine is high, your circadian rhythm is low, you know, the situation is perfect. So you get into bed and that prompts your body to know now we sleep. But in insomnia, if you spend hours and hours in bed not sleeping, that really weakens the link. So this is why if you're not sleeping after 15 or 20 minutes, and it's really not exact, but in that kind of ballpark, just get up and go out and do something else.
Dr Rupy: So do you think that's, using the Pavlov's dog analogy, do you think that's why some sleep aids work? So lavender pillow sprays, silk pyjamas, I don't know, sounds, all that kind of stuff. Do you think it's more from the training and the psychology point of view or that these activities are actually having a genuine effect in themselves?
Dr David Garly: Yeah, I think, I think it is that, that it's the association. Something aromatic particularly. I mean, we all know that that we have different kind of favourite senses and if you are quite a an olfactory person and you like that that kind of lavender smell, then that just helps to reinforce that you're now going to bed. And this is part of the reason behind a wind down routine that part of it is that you don't start really mentally engaging activities like answering your emails. But it's also starting that chain reaction off about going to bed. And this is what a lot of people do with their kids is that, you know, it's brush teeth, pyjamas on, bedtime story, bed, hopefully, you know, sleep. And it's just getting their mind just progressively more prepared for sleep.
Dr Rupy: Yeah, yeah, yeah. Brilliant. Um, look, we've covered so much. I there's so many more things we can go into. CBT, I mean, from my understanding and of the literature today, that's still the gold standard when it comes to treatments for sleep disorders.
Dr David Garly: Yes, indeed. Yeah. So for insomnia, this is the gold standard treatment recommended by NHS, NICE, the British Sleep Society, the American Association of Sleep Medicine. So everyone's quite in agreement about this. CBT in general looks at how your your thoughts or your cognitions and your actions or your behaviours influence something. It's used a lot for depression and anxiety, but it is fantastic for sleep. As a therapy, it's got a response rate of around 80%, which is really, it's really good. And there's good data on how you deliver it. So we deliver this through one-to-one sessions, which we think is important because of the uniqueness that individuals have and how people sleep is different that you do want to tailor how you deliver this. But you you can get this through apps now, which is great because one of the big problems is actually meeting the demand. Huge numbers of people have sleep problems, but there are very few places that you can actually get help from. So an app is one way that you can meet that demand. So I think that's going to be a really interesting thing for the next sort of five, 10 years is how to use, you know, digital resources to make meaningful differences in people's lives.
Dr Rupy: Yeah. I mean, the NHS is definitely bullish on the use of digital therapeutics, DTX, they're calling it, to meet that population demand. And I think the hurdle is probably getting people enthused about CBT because again, it's one of those things that is quite, it needs a lot of patience, it needs a lot of motivation in itself, rather than, oh, just take this pill because we've been sort of trained to believe that that's as effective as as other means.
Dr David Garly: Yeah. Yeah, I mean, it's it's more akin to fitness that you you need to go to the gym regularly to maintain that kind of physical fitness. And it's similar for, I mean, it's similar for how a lot of people approach depression that they have low mood, but they know that it's not, you don't do a short burst of therapy and then you're good. For some people, it's like that, but for a lot of people, it's actually about more daily, more weekly input and maintenance through, you know, through sometimes time-consuming methods, but it's worth it for them. And the same that if you struggle with your sleep, these are really tools, skills that you can do, but you do need to employ them. It does need to take up some of your time in order to have effect.
Dr Rupy: Yeah. Yeah. Absolutely. David, I think we've done it. I think we've gone through a lot of different areas there. And hopefully listeners have found that this has been useful and viewers, because I think there's just so much we can do to rectify the pandemic of poor sleep. And I appreciate all your work you're doing with the clinic as well.
Dr David Garly: Yeah, thank you. Yeah, no, it's it's all going well, but we'll see how policy is changing and people are putting sleep on the agenda. So we'll see how that translates to meaningful therapies over the next few years.
Dr Rupy: Fab. Fab. Epic.
