Sleep Advice & Wearable Sleep Tech: An Interview with Dan Gartenberg, PhD

What follows is a transcript for the podcast Improve Your Sleep: The Latest Tech to Optimize Your Sleep.

 Sub-section topics within the interview include the following:

1. Introduction
2. What Influences Sleep Quality?
3. How Effective are Sleep Tracking Devices?
4. What is the Best Wearable Device in the Market?
5. How Can You Use Technology to Improve Your Sleep?
6. How Light Can Be Detrimental to Your Sleep
7. When to Consult a Sleep Specialist
8. How Does Sleep Influence Cognitive Function?
9. The Connection Between Sleep and Immunity
10. Meal Timing and Intermittent Fasting
11. How Exercise Influences Sleep
12. How Dreams Affect Your Quality of Sleep
13. Toxins and Pharmaceuticals
14. What are the Other Options to Improve and Optimize  Sleep?
15. How Much Sleep Do We Need?
16. Biohacking Your Way to Better Sleep
17. Can Sleep Deprivation Cause Long Term Damage to Your Health?
18. About Daniel Gartenberg, PhD

Introduction

Heather Sandison, ND: Welcome to collective insights. I'm your host today, dr. Heather Sandison and I am so pleased to be able to pick the brain of Dr. Dan Gartenberg today. He is an expert, PhD who has focused his career on sleep. So, Dr. Dan, thank you so much for being here with us today.

Daniel Gartenberg, Ph.D.: Thank you for having me.

Heather Sandison, ND: I was just telling you how some of my most challenging patients in the clinic are the ones that never get that adequate optimized, great deep sleep at night. And it really seems to be a challenge for all of their symptoms to fully ever resolve if they can't get that optimal sleep, so I'm super pumped because I want you to help me answer all these questions about how to get them the sleep they need to heal.

Daniel Gartenberg, Ph.D.: I will try my best and it's a really complicated problem, but there's almost always three to five things that everyone can do to improve their sleep quality, it's just a matter of figuring out what those things are for you.

What Influences Sleep Quality?

Heather Sandison, ND: So let's start there. What are those three to five things that are typically influencing sleep quality?

Daniel Gartenberg, Ph.D.: So usually it involves a conversation and this is probably why it's a little bit tricky to give people, they'll use actionable things that they can do, because it's very personalized to them.

What I mean by that is, for example, if someone's an insomniac, I would never suggest for them to take a nap. Whereas if someone is an optimizer, you're already sleeping pretty well, I might suggest a power nap in ciesta time. So that's just one example of how in order for our medical system to really address this massive problem that impacts literally every chronic health disease, we have to take a much more personalized look at what is actually going on with the person, because at the end of the day, disease is a complicated thing and Western medicine loves to put people into these generic buckets.

You have insomnia, you have sleep apnea, but there's some science out there for example, that says there's 19 underlying types of insomnia. So what that points to is, this is a complicated thing, just the three to five things that I often think about, just to answer your question. Circadian rhythm, things like sleep hygiene and your sleep environment, relaxation, building that process of knowing how to relax your mind and letting go, because sleep is really about letting go and surrender, which is something that is often very difficult with everything that's going on in the world right now, and that also touches on anxiety.

And then understanding how technology is actually helping or hurting you. And we can talk about some of these devices now, they give you all this information about your sleep, but what can I actually do with that information to improve my sleep? And by the way, it's not always completely accurate too, which I often speak with my clients about trying to talk them off the bridge of their device that told them that they only got 2% deep sleep last night. So those are just a couple of things off the top of my head.

How Effective are Sleep Tracking Devices?

Heather Sandison, ND: Great. So tell me about your experience with these sleep tracking devices.

Daniel Gartenberg, Ph.D.: Yeah, so we got almost a million dollars in grant funding a couple years ago, and we just got another large grant to accurately measure these devices. And so I've been trying to do this for a long time, and we thought that in 2010, these wearable devices would change healthcare by exposing these patterns that people could use to really optimize their lives.

And I was involved in the quantified self movement back then. And what happened was, the bigger companies really didn't open up their data that much. So it would be hard for a scientist or a smaller company like me to leverage the devices in a meaningful way. And what's happened over the last couple of years, which is a really opportune time for the space is that larger companies like Apple have opened up their devices.

And so we ran a study at Penn State, where we hooked people up to the best wearables on the market, alongside a 16 channel EEG. And we published a paper in a leading journal sleep, where we basically quantified the accuracy of these various devices.

And one thing I'll say is, they're pretty good at measuring sleep wake, and I think we have one of the most accurate algorithms on Apple Watch for measuring sleep wake, but when it comes to sleep stages, they're not very good at providing absolute truth. You can kind of get relative truth from night to night, but don't necessarily trust the percentage of deep sleep that you're getting as a raw number from these devices.

Heather Sandison, ND: So I've been wearing one, and I've been wearing the Garmin Vivofit 4, and I'd love to hear what you think about it. And then I would go and read on the couch before going to bed and then get up, go to bed. And in the morning it would say that those hours I was on the couch reading, I had gotten deep sleep.

Daniel Gartenberg, Ph.D.: Oh, wow.

Heather Sandison, ND: So it was very clear to me that it was inaccurate. So what do we do with this data, what do we do with this information?

Daniel Gartenberg, Ph.D.: Yeah. And that's the tricky part. And there's actually a new concept in sleep called orthosomnia, which is basically the idea that these devices are doing more harm than good by creating anxiety around the data that's being produced, which is making people actually sleep worse.

And so we have to be ... A lot of this is about context. Understanding for example that, and being able to interact with the system, so we have a way of automatically measuring your sleep, but there also needs to be, for example, a diary where you could correct the misinformation.

A lot of these algorithms, and this gets a little bit technical are built in a way that basically, for the most part, a lot of the algorithms, it's a single algorithm that tries to generalize across everybody and it doesn't ... But when you look at someone's sleep patterns, there are these massive individual differences between people and lots of shifts with age. And the complicated thing about this and the winner in this space is going to be the person that understands how to make these algorithms much more personalized and therefore more accurate.

What is the Best Wearable Device in the Market?

Heather Sandison, ND: So right now, what do you think the best sleep wearable is on the market?

Daniel Gartenberg, Ph.D.: I mean, as far as form factor goes, and battery life, I mean, I love the, Ouraring the Biostrap is pretty good. You can get SpO2 or whatever with it, and so it has a good sensor. We use the Apple Watch, and I have a lot of belief in the Apple Watch just because I know the Apple Watch is going to be around for a while and I've seen how accurate their sensor is, I mean, it's Apple, they're going to make a good sensor.

And so we use and they have economies of scale. So we use the Apple Watch and leverage that a lot for algorithm work. There's certain problems with the battery life, but I think that they're going to overcome that eventually.

How Can You Use Technology to Improve Your Sleep?

Heather Sandison, ND: So these are all ways to track your sleep. What about using technology to influence your sleep?

Daniel Gartenberg, Ph.D.: That is kind of the golden goose in all of this. Everyone has these things for tracking their sleep, but golly, the Fitbit did it 10 years ago and we knew that that wasn't that interesting. These things have been around for a while, one device arrives the top, fall off, but none of them have really improved people sleep quality. And at the end of the day, that's what you want. You don't want to just mindlessly track yourself.

And so when I think about that, I think about relaxation training, cognitive training, cognitive behavioral therapy for insomnia is one thing. And then the exciting thing, that takes a lot of effort. What excites me more is ways of improving your sleep without any effort taken on your part, and when I think about that, I think about using sounds, light and temperature optimally in your sleep environment, both during sleep and even during the day to seamlessly improve the quality of your life.

Heather Sandison, ND: So where would you start with that, what sounds should we be listening to? What temperature should the bedroom be at? What about light, blue lights, red lights, therapies?

Daniel Gartenberg, Ph.D.: So this is when it gets really fun, right? And I'm sure you're familiar with a lot of the things I'm about to mention here. In sleep science, when they think about this they say quiet, cool, and dark is what you want in the bedroom at night. Even little things like taping all the lights, led lights, covering them all up in your room, if you have an alarm clock in your room, that's a really low hanging fruit thing to do.

One of the major things that I recommend to some of my clients is to get something like a happy lamp, if you're especially in a dark climate like England or something like this, where it rains a lot, humans should have at least a half an hour of sunlight every day. They're certain devices, you can just simply Google 10,000 Lux lamp. I have one that I'm actually using right now. I can show you.

So that's submitting a lot of lights and I just flip it on and to make sure that I get a half an hour of light every day, which will entrench my circadian rhythm. And knowing when to do that based on if you're a morning owl or sorry, a morning Lark, or a night owl, there's an optimum time to get that light exposure.

And then we're integrating with things like smart light bulbs. So we have the system where I'm not going to say it because it's going to mess with my apartment right now, but "Hey, X turn off the lights." And that'll start a whole chain of events where gradually your light environment shifts. It kind of brings you into this relaxing state. We adjust it to red light when that happens and then gradually dim out the light over time, to prime your brain ... Okay, sleep happens a half hour before sleep.

Let's change our environment during this time to prime our brain that now it's time to relax. And you can also imagine the wake up process, where you gradually get this morning light in the morning, waking you up in a gradual way. I know I'm rambling a little bit and I could talk about this for a while.

Another really low hanging fruit thing is having a sound mess during the night, you'd be a surprise and I've seen it in our lab. People's brains wake up throughout the night, all the time, without them consciously being aware of it. Even a healthy person like myself will have up to like five to 10 brain arousals at night of no conscious awareness of it at all.

I've seen air conditions turn on and waking up the brain at night. These little subtle sounds in your environment can hurt your sleep quality, so it just makes sense to have what we call a sound cushion that plays throughout the night to round out those disruptive sounds that could wake you up.

Heather Sandison, ND: Is this like a white noise machine, something like that?

Daniel Gartenberg, Ph.D.: It's like a white noise machine. And we have some deviations on it based on older people's ears. And we have some subtleties to making it slightly adjusting in order to be more effective.

Heather Sandison, ND: And is there a reason to like you said with light, where it fades in or fades out as you go to sleep and then gradually goes up in the morning, is there a reason to do that with sound?

Daniel Gartenberg, Ph.D.: Yeah. So we actually also alongside the light are having sounds playing for example, ocean waves to get you into this state in a multimodal way. And I know this for a fact, I was one of the first alarm clock apps back in 2010, like the right way to wake up is gradual. There's a lot of talk about waking up in a lighter sleep stage and all this stuff. Usually, you just want to sleep more and not wake up with that abrupt feeling of stress basically.

When you're constantly stressed, basically your cortisol awakening response flattens out, and you want this burst of energy in the day in the morning, but you don't want it to come from a stressful place. And when you wake up gradually, I'm really interested in these transitions between consciousness and unconsciousness. And when you gradually enter into consciousness, it's just a healthier way for your body to wake up and you're going to have less fatigue in the morning.

How Light Can Be Detrimental to Your Sleep

Heather Sandison, ND: So tell me a little bit more about light that can be detrimental. Are you in the camp of, you want to shut down your computer, your phone, you don't want to have your phone in bed, that blue light is going to be really detrimental to your sleep, or do you think that maybe it's not that big of a deal?

Daniel Gartenberg, Ph.D.: I am definitely in the camp that you want to reduce blue lights. So, I mean, one of the professors that I worked with at Penn State Anne-Marie Chang did some of the leading science on showing that blue light in particular from TV or an iPad is going to impact your circadian rhythm and negatively impact your sleep onset latency and your sleep quality.

And there's really good science on systematically manipulating these things, having people exposed to only darkness and looking at when they naturally sleep and all this stuff. There's just a lot of signs showing that our eyes are receptive to blue light in particular, and they also differentiate red light. It's thought maybe from an evolutionary biology perspective, a sunset is more red, which functions is like a cue that, okay, it's nighttime. And we didn't have light at night for 100,000 years, you know?

So there's a real biological reason why you don't want to have much blue light at night. That being said, if you get a little blue light at night, don't totally freak out about it. It's not like it ... And this is another part of the equation here. Sometimes people get so anxious about all these things that it does more harm than good. You want to reduce blue light, but don't be crazy anxious about it.

And this also speaks to a real tension that I try to be very sensitive to as someone who makes technology is, is this technology hurting or helping? And sleep is a really tricky space because so much of the time the technology hurts. That being said, I think there is a way to make it so you have the technology in your bedroom environment, but it's not doing more harm than good.

When to Consult a Sleep Specialist

Heather Sandison, ND: When is it appropriate for someone to just go ahead and say, get a sleep study, like go into the hospital, work with a professional, an expert, a specialist in sleep medicine, and really understand what's going on. And also what always comes up when I suggest a sleep study to any patient is, "Well, of course I'm not going to sleep well. I'm going to be in a sleep study." So there's the influence of the study on your sleep.

Daniel Gartenberg, Ph.D.: Yeah. And in psychology, it's interesting, that's called the Hawthorne effect, where the act of measuring the thing influences the thing that you're measuring and obviously with sleep, that's such a huge problem. It's hard to sleep with 16 electrodes connected to your head in an unfamiliar environment. And there's actually something in sleep science called the first night effect, where oftentimes whenever you go to a new environment, you have a worst night of sleep that night.

So yes, there's a lot of truth to that, and to answer your question, I'd say like 90% of the time people end up getting a sleep study because the doctor thinks that they have sleep apnea. I think that there should be more situations where a sleep study is recommended, but just based on where our healthcare system is right now, that's basically how it works.

One thing I'll say is, if the doctor thinks you have sleep apnea, you don't have to have a good night of sleep for them to measure that you have sleep apnea, they just need like a couple of hours of sleep and you can tell.

There are going to be differences from your home environment to the lab environment, and that could dictate some of the dosing and how you fit or fit to the mask and stuff. But yes, the environment will shift your sleep, which could make it not as diagnostic as it could be. But if it is something like sleep apnea, you can trust the sleep study.

How Does Sleep Influence Cognitive Function?

Heather Sandison, ND: So you and I both have an interest in how sleep affects Alzheimer's. I send the vast majority of my Alzheimer's patients, unless they've already had a sleep study, I send most of them to get one, because I want to be 100% certain that they're getting adequate oxygen at night. What have you found from your perspective on the influences of sleep on cognitive function?

Daniel Gartenberg, Ph.D.: Yeah, and I mean, this is really the cutting edge of science right now is basically the NIH tried all these drugs for Alzheimer's disease in the 90s and thousands, and none of them worked. And there was basically a reckoning at NIH, "What can we do here? Are there behavioral things that we can do?"

And Western medicine so often turns to these drugs when really the core of the issue, the causal thing here is oftentimes something behavioral that you do every day in your life and sleep is such an important thing in that. And about four years ago or so, they showed that the science is that they showed that sleep and deep sleep in particular, clean out beta amyloid plaques.

And they did this in some FMRI studies and they did this in some [inaudible 00:20:46] studies. And since we were studying deep sleep at the time, we were like, "What if we could get a healthy group of people, 65 plus who have insomnia, treat their insomnia and see if we can reduce conversion to Alzheimer's disease."

And that's the project that I'm going to be doing over the next year or two, is trying to heal people's insomnia, and by the way, this is not available yet, I'm not curing insomnia yet. This is just a project in the future. The idea would be, you cure their insomnia and then you reduce their conversion to Alzheimer's and we'll have various cognitive tests and biomarkers in order to determine in a clinical trial, if we're actually able to do this.

Heather Sandison, ND: Well, how exciting, congratulations on being awarded this NIH grant, that is a huge right there, that's an accomplishment, to write the grant and then be awarded. So congratulations, and I will be very, very curious what you see in those results. Go ahead.

Daniel Gartenberg, Ph.D.:  No, no, I appreciate it.

Heather Sandison, ND: So when do you expect them to be published? Do you have a timeline, I know with COVID everything's kind of thrown off, but ...

Daniel Gartenberg, Ph.D.: Yeah. So we're going to, it's probably going to be like, we have two papers published right now, one in the journal of sleep and one about using sounds to prime more deep sleep in people that's about to come out, but the clinical trial is probably not going to come out for another two years.

Heather Sandison, ND: Got it.

Daniel Gartenberg, Ph.D.: Science takes a long time.

The Connection Between Sleep and Immunity

Heather Sandison, ND: These things take time, we get it, we get it. We have a trial going on in my office as well. So tell me a little bit more about sleep and immunity, how are those things connected?

Daniel Gartenberg, Ph.D.: Yeah. I mean, we've actually known about this since Hippocrates, what is that, like 2000 years ago or something identified the link between sleep and immunity. And that was the first scientific perspective on sleep and immunity. We've known about this for so long. But recently, they've really started to understand the mechanisms behind all this stuff.

And basically, what they found is sleep impacts cytoplast, which is a type of protein that communicates with helper T cells. And when you're sleep deprived, you produce ... The communication of these cytoplast gets inhibited and you produce less helper T cells. Literally, you produce fewer antibodies.

And one of the professors that I work with at The University Of Arizona, this great researcher, Dr. Daniel Taylor actually did some of the pioneering research showing that you give someone an influenza vaccine when they're sleep deprived, versus when they're not sleep deprived, and they produce more antibodies for the vaccine if they got the vaccine when they had more sleep, which is pretty amazing.

So first and foremost, with this COVID stuff and everything, take the precautions and everything in terms of the mask and everything. I don't watch the media that much, but I feel like something that is often missed is these things that you can do beyond just the superficial mask thing, but inside your body, get enough sleep, and you will fight this virus more. Do things like intermittent fasting, and you'll be able to fight this virus more. There's just things that you can do every day in your life that are going to help you with this thing.

Meal Timing and Intermittent Fasting

Heather Sandison, ND: That leads me to another area of interest. Tell me about fasting. A lot of people are excited about a paleo diet or a keto diet, and then incorporating intermittent fasting. The most common way I hear people doing it is that they skip breakfast, which means they're having dinner closer to the time that they go to sleep. So what are your thoughts about the optimal way to organize your meal times and your intermittent fasting in relationship to sleep?

Daniel Gartenberg, Ph.D.:  I love this question because I'm an intermittent faster and a lot of times, and I do exactly what you just said. I find it much easier to not eat in the morning and I'm sort of a night owl. And this is something that I see a lot with people is they'll do the intermittent fasting thing, similar to how I'm doing it with skipping breakfast, but want to be a morning person.

And just to understand how this stuff works with the circadian rhythm, you want to try to have consistency in when your body wants to expend, take in energy and when your body wants to sleep. So you're kind of burning the candle at both ends by trying to wake up early and eat later. You want to align those things.

So if you want to be a night owl, do your intermittent fasting later in the day. If you want to be a morning person, do your intermittent fast, don't eat later in the day. And when you align these things, you get a stronger circadian rhythm and you have more energy. And that's that 24 hour rhythm that you can set based on sunlight exercise, and you actually have genes it's called chronobiology that gets expressed based on these environmental cues, sunlight being the biggest one.

Heather Sandison, ND: So I want to make sure I understand this. So if you're a morning person, do you want to wake up and have breakfast and then skip dinner?

Daniel Gartenberg, Ph.D.: Correct.

Heather Sandison, ND: And then if you're a night owl, you want to skip breakfast, have lunch and dinner probably, and then have a little bit more time between your last meal and sleep because you stay up late anyways.

Daniel Gartenberg, Ph.D.: That's exactly right.

How Exercise Influences Sleep

Heather Sandison, ND: Okay. That's helpful. And then tell me about how exercise influences our sleep. I can't tell you how many times a patient has finally started back on their exercise routine. And they're like, "Oh, I'm sleeping better." Imagine that.

Daniel Gartenberg, Ph.D.: I mean, yeah. So not so surprisingly eating healthy and exercising is good, and sleep is good for those things too. When you've slept more, you want to snack on less fatty foods and you can exercise more effectively. So I think about these things as the trifecta of health, they're all related to each other. I'm a little biased, I actually think sleep is the most important one, is sort of foundational.

But with the exercise, you want to do the same thing that I just described ideally. I mean, exercise is better than no exercise, so I'm not like crazy dictatorial about, it's better to exercise than to not exercise for the most part. But if you wanted to really optimize this, if you're a morning person, your most effective exercise time is probably two hours after you wake up. If you're an evening person, your most effective exercise time is probably an hour or two before dinner, just based on your circadian rhythms.

And the other part of this, with the exercise is there's some ... Matthew Walker, who's one of the leading experts in this space has published a paper all about deep sleep and one of the things that's been shown to increase deep sleep is exercise, and particularly increasing your body temperature throughout having a prolonged increase in body temperature of about 20 to 30 minutes is also shown to, there's some evidence that it increases your deep sleep.

Heather Sandison, ND: So would a sauna work?

Daniel Gartenberg, Ph.D.: And a sauna is an alternative. So that's like sometimes on the off day from the exercise, I oftentimes will suggest a sauna to the client.

How Dreams Affect Your Quality of Sleep

Heather Sandison, ND: So what about our dreams? What's going on when we're having more nightmares or we don't remember dreams, is there a difference in the quality of sleep we're getting? Is that a good sign, a bad sign?

Daniel Gartenberg, Ph.D.: Yeah. I mean, one of the frequent things that happens, especially if you have some anxiety and maybe there's a stressful thing happening in your life, is you'll pop up in the middle of the night from a bad dream.

And the reason why this usually happens in the middle of the night is you're most likely to be having these intense dreams and you have more REM, and that's when you dream is when you're in rapid eye movement. Basically, your whole body is paralyzed and your eyes are darting around and your brain is functioning very similar to consciousness.

And it's sort of a magical thing to see in a sleep lab. And you're having these vivid dreams that are basically integrating all the events from the day into your longterm personality and memory. And so deep sleep basically down-regulates everything and REM integrates. And that's why both deep sleep and REM are very important.

And in sleep science, we think about this, the theory around this, that I'm speaking to is something called the synaptic homeostasis hypothesis founded by this professor at University of Wisconsin, Giulio Tononi. And it's the basic idea that sleep is foundationally how we construct our reality.

And so if you had some kind of traumatic thing that happened to you and it doesn't even have to be something crazy traumatic, it could be minor traumas and whatnot, a lot of times you'll process that with a nightmare or a bad dream. If you have something like PTSD, what's happening is your brain has over entrenched that trauma and it just keeps on going back and back to it in a positive feedback loop.

I think there are ways to relax people when they're transitioning into sleep. Having this relaxation process and being feeling in that comfortable at ease state before you enter into sleep is a way to mitigate some of these dreams and nightmares that could wake you up.

And so the simple suggestion here is instead of watching that fifth episode of CSI on Netflix, which is going to activate you at nights, read a book, do something that's less activating. The ocean waves is good, but everyone really, I believe should have some kind of relaxation process that prepares them for the journey of the night.

And I don't have strong opinions on what that is for people, but I think everyone needs to find out what it is for them and do it.

Toxins and Pharmaceuticals

Heather Sandison, ND: Yeah. What is the role of toxicity? So we focus a lot in my clinic on environmental medicine and making sure that people aren't exposed to things like mold and heavy metals and chemical toxins.

Another big one that comes up with sleep is all of the pharmaceuticals, so like the benzodiazepines and the SSRIs, and even anti-histamines are used to help people to get to sleep. But I wonder, especially as they become addictive and I question whether or not they are actually improving sleep or they're just making you forget that you had a shitty night of sleep.

Daniel Gartenberg, Ph.D.: Yeah. Yeah. So first and foremost, I just have to say that I'm not a clinical psychologist, I'm a cognitive psychologist, so ask your doctor about this stuff. But my understanding about the hypnotics and the benzodiazepines is that sometimes, every once in a while, they're not meant to be used on a chronic basis.

And this is a big thing that we're trying to say in our grants is that the recommended treatment for a sleep problem, and this is a consensus report from the leading experts in the field, is not a drug. It's cognitive behavioral therapy for insomnia and that's behavioral things that anyone can do with a trained professional to improve your sleep health, that takes into account behaviors, thoughts, and feelings.

The drugs have this issue where oftentimes they're addictive. And so you have to keep on taking more and more. And you're exactly right, they knock you out. So you have this perception that you're sleeping better, but oftentimes when you look at the sleep quality, it's worse. So it can have this negative impact.

And so before taking a drug, why not try at least, with some of these behavioral things that are going to be less risky basically. And this is one of our major motives here, and it's just too bad that our healthcare system is designed in such a way, where the healthcare professional is so often motivated to write a drug prescription. Because I mean, I don't blame them necessarily, but they don't have the time or the economic incentive to deliver the suggested treatment, which is cognitive behavioral therapy.

Heather Sandison, ND: But it feels like most providers and certainly patients as well, right now is a very stressful time, I think, in history. And so a lot of people are, you'll see, the studies are saying that there's 30% more of these anxiolytics or insomnia drugs as benzos, primarily being prescribed. And I think patients are also trained to ask for them, right?

It goes both ways. Doctors don't really know, okay, well, who do I refer to for CBT to help with their sleep issues or are they going to be able to get to that person? Is their insurance going to cover it? And the patient is already sitting there going, "Hey, can I have some Ambien?" So why not? Yeah.

Daniel Gartenberg, Ph.D.: Exactly.

Heather Sandison, ND: It feels like there's like a cultural societal shift that needs to happen where patients are informed that, hey, there's some risk associated with that intervention and there's other better, scientifically proven, better option for you.

Daniel Gartenberg, Ph.D.: Yeah. And I mean, this is the struggle of Western medicine. I think is something that our society is ready for now, but we're so good, western medicine is so good at these acute issues. You break your arm, they're great at that. But these chronic health problems and the science of behavior change, we just have a long way to go when it comes to these things. But I think, with this shift to digital technology and digital therapeutics and all these wearables, I think there's an opportunity here, to really change the zeitgeists around all of us.

What are the Other Options to Improve and Optimize Sleep?

Heather Sandison, ND: Yeah. So going back to some of my most challenging patients, if they have worn the wearables and now I'm questioning that. Maybe that's not the best thing for people to be doing based on some of the things that you've shared. But if they've worn the wearables, they know what's going on with their sleep, they have their exercise and diet timed right. What's another direction that you would go at this point?

Daniel Gartenberg, Ph.D.: And they're still having problems falling asleep and staying asleep?

Heather Sandison, ND: Yeah. Yeah. So those are my primary questions. Can you fall asleep? Can you stay asleep? And then do you feel rested in the morning? So if there's an issue with any of those three things, then I consider their sleep not optimized.

Daniel Gartenberg, Ph.D.: Sure. So usually the threshold that I look at, through this lens is if you're spending less than 85% of the time in bed asleep on a regular basis, that suggests that you might be having a problem. One of the things that you and your patients could look into, which is one of the ... If they are at that threshold, where they're really having a problem falling and staying asleep, first and foremost, I'll try to address that.

With the relaxation training, where we usually introduce a relaxation during the day at first, to get them trained up and then gradually introduce it into the ... SometimeS if your someone that has problems falling asleep, the bed is actually stressful. So you don't want to necessarily start training on your relaxation when you're in that stressed out state. So you basically introduce it in the day. And then once you build up your practice, you gradually introduce it in the nighttime. If there's really still a problem ... Were you going to say something?

Heather Sandison, ND: Well, staying asleep. What if it's like 3:00 AM wake up, can't get back to sleep?

Daniel Gartenberg, Ph.D.: I mean, sometimes it's a hormonal thing and a lot of times, I'm trying to narrow down if there's some kind of underlying pathological issue, i.e. sleep apnea. Sometimes even bedtime partners or a pet could be the underlying issue. Whether it's a restless leg syndrome thing, traumatic brain injury thing, menopausal thing. These are all possible comorbid things that I'm trying to look at when I'm giving this coaching based feedback.

But in cognitive behavioral therapy for insomnia, if you're still having an issue, you do something a little bit counterintuitive, which is you actually restrict the time in bed and that's called sleep restriction or sleep compression, which is the friendlier version.

But the idea is you actually either push the bedtime forward or you push the wake time back, so you're spending less time in bed. And while you're doing that, you're doing all these other behavioral things and cognitive training things and relaxation at the same time. And you will be tired because you're spending less time awake in bed, basically.

And once you start hitting that 90% threshold, you gradually move the bedtime back. So it's like shifting your patterns a little bit to make you more tired when you go to bed, to ensure that you sleep through the night, if that makes sense.

Heather Sandison, ND:  Totally makes sense. I've also heard this idea proposed that perhaps humans get two sleeps, that there is this time that you're meant to be awake potentially in the middle of the night and that it's not a terrible thing. Do you subscribe to that?

Daniel Gartenberg, Ph.D.:  I mean, I think that for the most part, we're monophasic. But again, speaking to the variability of people, we do have this shift between deep sleep and REM, where it's often normal to pop awake. And it's totally normal to wake up throughout the night. If you wake up a couple of times throughout the night and go back to sleep, it's totally normal.

It's been documented and it's true, some cultures would, in England and stuff, I think in the 1700s. They'd wake up in the middle of the night, have a party, have a tea party and then go back to sleep and do some chores and go back to sleep. A lot of this stuff is cultural.

I think for the most part, and they've studied indigenous tribes and stuff and really looked at this. I think for the most part, we're monophasic, we're meant to sleep for a prolonged period of time. This polyphasic stuff is totally bonk for the most part.

But when we were thinking about this also, speaking to the cultural stuff, it's natural for some people to be night owls, some people to be morning larks, yet our society is so biased against the night owl. We're totally geared towards the morning person. But evolutionarily, it makes sense for there to be morning people and night owls, because you want someone to always be awake in your tribe, because we were tribal creatures for so long.

And that's why this also shifts with age probably. When you're a teenager, you're a night owl because you're trying to break away from your parents who are morning larks. And you're trying to tread your own way and all this stuff. So, I mean, they've done really cool science where they'll look at these tribes and they'll say things like, there was only 30 minutes over a three month period where the whole tribe was asleep at the same time.

There's a reason that we have these different circadian rhythms. It's an evolutionary advantage for someone to always be awake in the tribe. So understanding where you sit on that continuum and doing the things in your life to entrench your rhythm is really one of the key things here.

How Much Sleep Do We Need?

Heather Sandison, ND: I haven't heard that perspective. That's really insightful. And this idea also that sleep is so individualized. I feel like from a medical perspective, I say that all day long, but I've never really applied that to sleep. I think I've heard over and over that those hours before midnight are the most important and you have to get to bed before midnight. Otherwise, you're not going to get that deep sleep, but you're saying no, that's bullshit. You can go to sleep when it feels right for you, as long as you're consistent.

Daniel Gartenberg, Ph.D.: Yes. That is what I suggest to people. I know that others don't say that. But for the most part, consistency is key, knowing yourself is key and some of these generic thing. I mean, look, the media is always wanting to give these simple generic responses because they're horrible at nuance.

And so, I tried to articulate the nuance to a reporter once and the headline ended up being, eight and a half hours is the new eight. When I was really trying to say is, there's individual differences here and the Society of Sleep Medicine has said in a consensus report, for example, that adults need between seven and nine hours on a regular basis. To get eight, you usually need to spend more time in bed is why she said eight and a half is the new eight.

But what I'm speaking to here is, there's a lot of variances, things like your sleep need. That's a two hour variance in sleep need. So really knowing yourself in terms of how much sleep you need and when your most effective as a night owl or a morning person is so important to solving this for yourself.

Heather Sandison, ND: So how would someone go about solving that? Is it just paying attention or do you suggest working with someone?

Daniel Gartenberg, Ph.D.: Yeah. I mean, getting feedback from a coach or an expert is always helpful I would say. I mean, I can give you a couple of simple hacks right now to try to figure it out. One of the things that you can do is, oftentimes if you sleep in on the weekends, it's a pretty strong indicator that your sleep depriving yourself on the weekdays. And so that's one thing that we look at, if you're tired during the day, I mean, that's a simple question.

Sometimes though, you've been tired during the day for so long that you don't even know what it's like to not be tired. So understanding that and what people with sleep apnea, for example, will be shocked sometimes when they get the treatment and they're like, oh my God, this is night and day. I had no idea.

The analogy I use here is a fish in a fishbowl, doesn't know it's in water because it sees it all the time. So yeah, I mean, just know if you're getting less than seven hours on a regular basis, it's highly likely that you're not getting enough. There's such certain, very small percentage of the population where that would be okay. So that's one thing.

I try to really listen to the person to figure out if they're sleep deprived. There's these simple tasks that are more sensitive to whether or not your sleep deprived than me asking you and they're called vigilance tasks. This is actually what I studied in my PhD work. And we have some games that we made, where basically, they're very simple reaction time tasks that are sensitive to your fatigue. And that's a more, if you're really into biohacking and stuff that's, if you want to understand that, that's one thing that you can do

Heather Sandison, ND: Are those publicly available? Is there access to those?

Daniel Gartenberg, Ph.D.: Yeah. It's called, Mind Metrics is one of them that we've made. The science is called psychomotor vigilance tasks, if anyone wants to look that up.

Heather Sandison, ND: Yeah. We'll put links in the show notes. That would be really cool.

Daniel Gartenberg, Ph.D.: Yeah. Yeah. And we're putting them in there, my software by the way, is Sonic Sleep Coach and we're going to be putting it in there too.

Biohacking Your Way to Better Sleep

Heather Sandison, ND: Cool. So what was that, you said you had two primary suggestions, hacks and it was them, just lay them out for me again.

Daniel Gartenberg, Ph.D.: Oh, sorry. I forgot the second one. So the first one is whether or not you sleep in on the weekends. And then actually I forgot, sorry. Thank you. The second one is go on a vacation in a stress free Caribbean style vacation, not a busy one.

Heather Sandison, ND: Yes, please.

Daniel Gartenberg, Ph.D.: Yes please. And try to go to bed the same time every night and you'll fall into a natural rhythm. And that amount of sleep is likely the amount of sleep that you need when you're ... For example, even I will sometimes, when in a crazy work mode, will activate almost like a ... I'm not bipolar or anything, but I can activate a [manic-y 00:15:20], state where I need to sleep less because of my external environment is pushing me in this way.

So the idea is, take out those environmental pressures and see how much sleep your body naturally needs. When I think about this with my professor, he says, "Sleep to affect." Your body knows how much sleep it needs. If you can sleep, your body probably needs to sleep unless you're depressed or have a thyroid issue, basically.

Heather Sandison, ND: So this is great because we can debunk all of these sleep myths. What about the one that sleep is like a bank account? So if you've been sleep deprived for a long time and you go on that Caribbean vacation, it may feel good for you to get 10 hours of sleep or 13 hours of sleep for a week. But then once you've refilled your bank account, once you're not in the negative anymore, then you feel better. Is that true? Have you seen that play out or do you think that no, you can just go on vacation and that'll be your set amount of sleep that you would need, regardless of how sleep deprived you were?

Daniel Gartenberg, Ph.D.:  Yeah. So you can store sleep to some degree, but if you sleep deprived yourself, you can't fully get that sleep back. So we can all relate, you just went out late one night and you got five hours of sleep and then the next night you have a recovery sleep and there's actually different types of naps you can do to prepare for some of these sleep deprivation things, that have been shown to be effective.

So there's like appetitive nap that you can take after you've been sleep deprived to get some of that energy back. And there's actually something called a prophylactic nap that you can take, in preparation for being sleep deprived, to actually make you less sleep deprived. And that's sometimes recommended for shift workers and stuff, who are anticipating their schedule. You take a well-timed nap and this stuff gets complicated and you have to work with people's schedule. But the simple answer is, you can store some sleep to some degree, but if you sleep deprive yourself, you're never able to fully get back the sleep that you lost.

Can Sleep Deprivation Cause Long Term Damage to Your Health?

Heather Sandison, ND: And can you do longterm damage by sleep depriving yourself? 

Daniel Gartenberg, Ph.D.: Well, I mean, there's classic things like the Guinness Book of World Records guy who went like 12 days and had permanent psychological issues. I mean, look, sleep impacts organ. If you don't sleep, you die. I mean, there's a weird neurological disorder that some people are born with not being able to sleep and you die after a while. It impacts every single organ of the body, so do it.

Heather Sandison, ND: So get some good sleep, that's the take home message here.

Daniel Gartenberg, Ph.D.: Just do it.

About Daniel Gartenberg, PhD

Heather Sandison, ND: If people wanted to learn more about what you are doing at Sleep Sonics Coaching, where would they find out more? What's the web address? Are you on social media?

Daniel Gartenberg, Ph.D.: Yeah. You can check out sonicsleepcoach.com. We actually have an app that is going to be free for you guys for 30 days just to try out. And we have a bunch of meditations, the sound mask, the smart alarm and I think one of the most accurate sleep detection systems. And you can check out, my Instagram handle is Dr. Snooze and I post stuff on sleep, a bunch of stuff.

Heather Sandison, ND: Thank you, Sonic Sleep Coach. I had gotten that wrong.

Daniel Gartenberg, Ph.D.: All good.

Heather Sandison, ND: So the other thing that I really appreciated about what you've been saying today is just these foundational pieces, sleep, diet exercise. I typically add stress management into my set of foundations. And you just mentioned that meditation is part of what you guys are offering at Sonic Sleep Coach. How important do you think it is that people have some sort of stress management practice or strategy, even before looking into how to optimize sleep?

Daniel Gartenberg, Ph.D.:  I mean, that is one of the main tools I think about when I think about optimizing sleep. I mean, I think there's lots of different types of meditation. Some are more or less passive, but one of the things that is most recommended in sleep science is progressive muscle relaxation, where you basically tense different muscles in your body. We have that in our software. I like it because it's both a physical and a mental meditation.

I personally also really like to do a gratitude meditation before sleep to set my mind in a more caring and giving place, queuing my mind for that. And maybe I'll have a more caring and giving dream later on, so I'm totally with you. When I think of stress management, I think of it within the field of sleep almost, within that pillar, but I can see it being its own pillar too.

Heather Sandison, ND: And then talk me through, if I download the app, then is there a wearable that I could order to go with it or how does this work?

Daniel Gartenberg, Ph.D.: Yes. So our whole thing is just, we just want to work with the best things. So we integrate with Apple Watch and a lot of the other major wearables out there. And so we're just trying to do the hard science and work with all the wearables and do the things to not just track, but to physically improve. That's my goal here.

Heather Sandison, ND: Fantastic. So the app acts as a coach, essentially.

Daniel Gartenberg, Ph.D.: Yes. Yeah. And you can get email coaching and if you really want to get deep into it, I offer personal coaching as well.

Heather Sandison, ND: Fantastic. I can think of people that would be extremely valuable for.

Daniel Gartenberg, Ph.D.: Thank you.

Heather Sandison, ND: So Dr. Dan, it's been an absolute pleasure having you today. Any parting ]insights on sleep for our listeners?

Daniel Gartenberg, Ph.D.: My main takeaway is just think about your life. Think about your schedule. And I know that there's one or two things that are unique to you that you can do tonight to improve your sleep quality.

Heather Sandison, ND: Fantastic. Well, and with that app, you might even identify them faster.

Daniel Gartenberg, Ph.D.: There you go. Thanks.

Heather Sandison, ND: Thank you so much for being with us, Dr. Dan. And as always, thank you to all of our listeners for joining us today. It's been a pleasure.

Daniel Gartenberg, Ph.D.: Thank you so much. Have a good sleep.