“The Evidenc

morning, they may have to wake up at 4 o'clock in the morning to get to those jobs. And then when they come home sometimes they may have two jobs--one that goes from the afternoon into the evening. Often these are families that have just one parent. You have this huge burden of child care in the evening and then you are waking up at 4 o'clock the next morning to get to your job again. So there is an economic and employment disparity that forces poor sleep in these communities.

Amit: We have a lot of interest from people around the world. Isabel from Germany says, “I'm one of those people that are sleeping less and less and can that be reversed? I've done this for years. Is there any benefits to changing now rather than in my late sixties?”

Matt: There is always benefit. And one should always hold out hope to try and obtain the very best sleep that your brain in that time of life is capable of. As I said some of these sleep hygiene principles--you can just Google sleep hygiene--should really help your biology at this stage of life, which is about finding the best chance of producing the best quantity and quality of sleep that you can have. So I think there is usually always room for improvement.

Kozo (a caller): Hi Matt. Thank you for this wonderful information. I was really struck by when you said that sleep and bad sleep patterns can actually cause disease. I'm wondering if you know if there's any research being done on sleep being a therapeutic for disease. So let's say you are diagnosed with cancer, is there any research being done where they require people to sleep in a certain way for a certain amount of time and then check and see if that affects the disease? Also, is there any movement or any research being done on sleep and hospitals, because it seems to me like you said sedation is not sleep? And in a hospital environment it seems like sleep is almost impossible. They come in and check on you. You have a roommate. They are moving things around. They have lights on. I'm just wondering if that is causing more disease or causing more mortality?

Matt: So the answer to both of those questions is an emerging area but the movement isn't really in full swing right now. The evidence is concrete. We have good evidence and clinical studies in animal models that suggest that if you bi-directionally perturb sleep you can accelerate or retard certain diseases. A good example of this is cancer. If you are fighting a battle against cancer and not getting sufficient sleep, we now know that the cancer will grow more aggressively and more quickly. So people are now trying to think about prioritizing sleep as an agent that will aid in in the fight against cancer. Some really powerful and quite disturbing animal studies are out there showing that if you are short changing animals who have cancer of sleep, that cancer can increase in its speed and size and growth by 200%. So the evidence is that sleep is causal and bi-directional. It has forced people like me to try and advocate to medicine and doctors that we need to start prescribing sleep. Not prescribing sleep medication but prescribing sleep as the elixir of life, as a panacea for good health, and perhaps one of the best Archimedes levers that we can think of for actually brute forcing health under the attack of disease. And we will see more of that in the future.

In terms of sleep in the hospitals, you are absolutely right. There's now a slow but growing recognition that it is a major problem. The place where I would argue you need a good night's sleep the most is perhaps the last place that you get it, which is a hospital. And one of the things that I write about in the forthcoming book, is why don’t we do what we do on transatlantic flights. We give people a free eye mask and a free pair of earplugs. Add a small cost and it would help significantly with improving sleep. Now we've even seen evidence in neonates in the Intensive Care Unit that if you regularize the sleep they will exit out of the Neo Intensive Care Unit in half the time. It's a dramatic improvement in health.

Albert from Oakland: Thank you so much. So, what I'm hearing is that a nap during the day is not really encouraged, which is contrary to a lot of older stories of certain cultures that may have benefited from the tradition of a siesta. Or if you take a look at children for example napping is encouraged for them for brain development. So is there a shift that happens at a certain age where it is no longer required or needed?

Matt: Let me be very, very clear about naps and their use. Firstly, children should be napping. Children very early in life are what we call Polyphasic sleepers, which means they have many phases of sleep. Then they become biphasic, which means they have an afternoon nap and then they sleep at night. If you do look at cultures that are touched by electricity, many of them are biphasic. They will sleep six and a half or seven hours of sleep at night and then they will have a siesta-like phase in the afternoon. We may be in modern-day societies not sleeping in the way we are naturally programmed. And I think there's good evidence for that. But here's the problem. Most people are not able to regularly nap. And it is in that context that sleep medicine now advocates against napping.

So if you can regularly nap during the day, day after day in a very stable manner and you can do so early in the afternoon, then napping is advantageous only under the condition that you are not having problems falling asleep at night. But if you cannot nap regularly then it is not advisable. Secondly, it is not advised that you nap later in the day. And finally, for older adults, if you are napping and having problems with sleep at night it is strongly advocated against that you don't nap during the day and that you try to just push all of that sleep pressure into getting a good night's sleep throughout the night.

So children—great to be napping. It is natural. Human beings, innately, we may be biphasic. We may be born natural nappers throughout our adult life. It is just that in modern day society very few people can nap regularly and if you can't then it can be problematic especially late in the day.

Amit: Do natural supplements support sleep like calcium and magnesium or melatonin?

Matt: Sadly the evidence isn't particularly strong in clinical trials. If you are in a severely nutrition deficient state then that can have an effect on your sleep and I want to be clear about that, but many of the homeopathic medications and even melatonin—and this is melatonin in the context of once you're in a new time zone and you’re stable and you're not suffering from jet lag—homeopathic medicines and melatonin for the most part have not held up under clinical trials to be any more efficacious than a placebo. If you are taking melatonin or some kind of a homeopathic medication and you feel as though it helps you sleep, my recommendation is keep taking it. The reason is that the placebo effect is the most reliable effect in all of pharmacology. What that tells us is that there is such a thing as mind over matter, and science is now grappling with this. It is acknowledging the placebo effect and we should take advantage of it.

Caller: Hello my name is Suzanne. Our new president (President Trump) concerns me in that he stays awake tweeting all night Is he going to be able to judge adequately not sleeping?

Matt: Great question. And it strikes at the very heart of one of the biggest problems with sleep. The answer is no he's not going to be able to judge based on the scientific evidence. The fact is this your subjective sense of how well you are doing when you haven't been sleeping enough is a miserable predictor of objectively how poorly you are doing with insufficient sleep. What I mean by that is you don't really know that you're sleep deprived when you're sleep deprived. The analogy is a drunk driver at a bar who has had five or six shots of vodka and a couple of beers and who may pick up their keys at the end of the night and say, “I am fine to drive home.” And your response is, “No, no, no, I know you think you're fine to drive, but trust me you are, objectively speaking, certainly not.” It’s the same with sleep deprivation, and we've got great data demonstrating this. That's the reason why people will say to you, “No I'm actually one of those people who can survive on 6 hours of sleep or less.” That is sadly not true based on the scientific data of about 17000 studies; the number of people who can survive on 6 hours of sleep or less without measurable impairment rounded to a whole number and expressed as a percent is zero.

Mish (a caller from New York): I am now questioning the benefit of my sleep pattern after listening. I’m a senior, I fall asleep as soon as my head hits the pillow and I sleep straight through for about 4 hours. I wake up between one and three times for a few minutes, go back to sleep right away each time, and then wake up as soon as my feet hit the floor. Is there any quality to the sleep pattern?

Matt: You're worried about the waking up throughout the night— is that your concern?

Mish: Yes.

Matt: As long as you are finding that you're able to fall asleep quickly after those awakenings without a problem, and secondly during the day if you are feeling restored by your sleep and you're not feeling as though you're nodding off, or you're lacking in energy, then the chances are that the sleep you're getting is sufficient. But if it's not, or you're concerned and don't think your sleep is sufficient, definitely do go and see your doctors and let them know about those sleep problems. But from the sounds of it, it doesn't seem like you're suffering one of the two forms of insomnia. One of them is called sleep onset insomnia which is having trouble falling asleep and the other is sleep maintenance insomnia which is trouble staying asleep where you wake up throughout the night and find it difficult to fall back asleep. It sounds like you do wake up, but you're able to get back to sleep.

Amit: I'm going to go to one of our online questions: “Do you have any recommendations for getting smartphone apps for monitoring the quality of our sleep? Have you heard of things like motion eggs and are there techniques for getting dream sleep and non-dream sleep?

Matt: It's a little bit of a mixed bag out there in terms of these sleep assessment tools, and I should also mention that I work with a start-up company up in San Francisco as the Scientific Advisor. But I think right now the apps that track your sleep are perhaps not particularly accurate. I think we'll get there very soon, and in the next 2 to 3 years, we will have good sleep-tracking devices, and I'm excited about that because right now technology is one of the biggest enemies in the bedroom for sleep. But I think it's going to be technology that is our salvation. And the reason is this, there's a common adage in medicine which is, “What gets measured gets managed.” And for so many of us for so many decades we've never really had a handle on how we are sleeping because we couldn't measure it apart from our subjective sense of what time we turn the lights off and what time we woke up--and that's not a very accurate rendering of our sleep. I'm very hopeful that soon we will have wearable technology or technology in the bedroom that accurately tracks our sleep. And once we take control of our sleep we will be able to better manage our sleep, and I think that's fast going to happen and it will only be good for society.

Pranidhi (a caller) What do you think of advocacy for institutional change in this realm?

Matt: There is just no way to cheat the brain and body out of sleep. One way or another it will catch up to you whether it's chronic sleep deprivation across a lifetime, leading to chronic disease and ill-health, or it's the tragedy of mortality and this brings us back to road traffic accidents. When you are not sleeping, you are having micro-sleeps at the wheel. Sometimes your eyelids will partially close. Now at 65 miles per hour if you have a micro sleep that usually lasts just for 1 or 2 seconds, at 65 miles per hour that means you'll drift from one lane to the next. So at that moment for those 2 seconds there is a one ton missile traveling at 65 miles per hour and no one is in control. And that can lead to fatal consequences not just for you but for those around you on the road. There’s sadly no way to short change it. It's non-negotiable; it's a life support system. It's a biological necessity, and it’s Mother Nature’s best effort yet to counter death.

Alissa (a caller): I work sling shift so I do have an odd schedule but I try and keep my sleep regular. And this is for all the people who can't do what you describe and go to bed an earlier time—is that still okay as far as maintaining your sleep regularly but working at odd, different times?

Matt: Right now shift work is a real problem and working at different times of day causes that normal window of sleep to slide across the 24 hour clock face. That really isn't an optimal way to be falling asleep. Right now the advocacy in shift work is, if you're on a shift, try to maintain that shift for long durations of time, and then come off and have a long period of recovery, and then go back on that stable shift. The biggest problem with shift work is having shift work that is inconsistent. Now technology is going to help try to limit the burden some, but people still make that sacrifice for us and we need to make it better for them and this is one of the ways that seems to be best. If you do need to do shift work, maintain that stable shift; that off normal natural rhythm shift, for a long period of time and once that shift ends give yourself a long period of recovery before you have to go into that same shift again.

Unfortunately if you give yourself eight hours of sleep during the day versus eight hours of sleep at night, the sleep you get during the day is not the same that you get at night; it is more fragmented, and it's not as deep quality of sleep. It doesn't necessarily contain the same stages of sleep. The reason is that biologically you're not designed to sleep during the day. However, other species are. We're not nocturnal species; we are a diurnal species. And so the recommendation is make sure you do give yourself 8 hours, that's critical, but do realize that it's probably not going to be as good a quality as 8 hours of sleep during the day as it would be 8 hours at night.

Just a little bit of a caveat on that: everyone has their own circadian preference, the fancy name is pronotype which means some people are owls, and some people are larks. Some people like to go to bed late and wake up late. Others like to go to bed early and wake up early. It's a natural variation and it’s determined by genetics. It also changes across the lifespan, of course. If you're one of those people who like to go to bed late and wake up late then the schedule of going to bed at 2 am and waking up at 10 am, may actually be fine. It fits perfectly with your biological rhythm. But if you're someone who is a lark then you would like to go to bed at 10 o'clock and wake up at 6:00, then going to bed at 2:00 am and waking at 10 is not going to be optimal for your biology.

Amit: This is a very hot topic. We really appreciate you coming to share with us today. As a community how can we support your work?

Matt: I think I would just ask people to propagate the good work. And rather than necessarily support my work try and learn more about sleep and advocate more the critical thing for us to do as a society is to get rid of the stigma of sufficient sleep. This is one of the major problems right now that we face is in the civilized world is that we have associated getting sufficient sleep with this thing called laziness. That we think people who get 8 hours are slothful, and they're not productive and the opposite is true. So as a society we need to be proud of our sleep; we need to reclaim our right to a full night of sleep without embarrassment and without that terrible stigma of laziness. And in doing so, we may all feel what it's like to be truly awake during the day. So please don't chastise others for getting sufficient sleep. As parents we shouldn't chastise our children because that parent-child transmission of sleep neglect is powerful and it is problematic. That's the only support I would ask for.

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