What's the Deal with Sleep?

Perry: [00:00:00] Emily back when I was, um, a resident in internal medicine at the hospital, University of Pennsylvania, we used to do these 30 hour call shifts. So you'd get there at like six in the morning and you'd stay, you know, all the way through the night, and then you'd leave at 1 p.m. the next day.

Emily: [00:00:20] That's no good. That's not good. That's not a good doctor. I do not want to see you at noon on that day, that's for sure.

Perry: [00:00:25] Well, that's this this episode on sleep had me reflecting back with mild PTSD on, like, the state I was in at 1 p.m. driving home. By the way, I had a very good friend in this situation who got in a car accident and lacerated her spleen, and it had to be removed. And like, this is a this is a real problem. They limit the hours. Doctors can work to shorter than 30 now, thank goodness. But one of the experiences we all had after being awake for 30 hours and going home is something we labeled post call temperature Dysregulation, [00:01:00] which I have never seen officially studied. But it was this phenomenon where you would just be like shaking with cold. Like you could no longer that something was.

Emily: [00:01:11] It was like, that was like, oh, we got to give up on temperature regulation.

Perry: [00:01:14] Yeah. It was just, it was like something was fundamentally broken. And, you know, I would, I would drive home and I would stop. This is horrible. I would stop at this amazing little bodega and get like a chicken cheesesteak because I was so hungry and cold and shaking. And I would sit on my couch and I would, like, eat the whole cheesesteak, you know, still in my scrubs. And then I would, like, lie on the couch and fall, fall into the, like, unhealthiest coma and then wake up, you know, at 9 p.m. and be up for a couple hours and then sleep again and then go in the next day. It was it was crazy. And it's just one of many examples of how much we take sleep for granted. Because when you don't get it.

Emily: [00:01:55] You are in trouble. And we're going to talk about that today and [00:02:00] also why it makes you eat too much cheesesteak and, uh, be really cold. So let's do it. I'm Emily Oster, I'm an economist and a data expert.

Perry: [00:02:13] And I'm Perry Wilson. I'm a medical doctor. It's Thursday, June 18th, 2026. And this is wellness actually, because you're getting a staggering amount of health and wellness information nowadays from every source imaginable. And some of it is awesome.

Emily: [00:02:28] And some of it is, well, actually bullshit. Fortunately, we're both people who know how to read studies, how to parse the data, and can tell you what's worth thinking about and what you can safely ignore.

Perry: [00:02:41] But before we dig in a note that this podcast is for educational purposes and should not be construed as medical advice. We don't know your unique situation, so talk to your doctor for personal health decisions. This week we're asking what's the deal with sleep? Emily and I will give the official smash or pass, and [00:03:00] then we'll get to your question of the week. But first, let's do the health news roundup after the break. And we're back with the health news of the week. This is a special health news because my intrepid co-host Emily is on vacation. So you get a solo Perry set of health news. But don't worry, Emily will be joining us when we ask, what's the deal with sleep very shortly? So buckle in, folks. It's just me today and we're going to start with Screwworm. I've been getting a lot of questions about Screwworm and the Screwworm response lately. So what's going on with this invasive species? A couple of things that people need to know about Screwworm. Number one, they're not worms. Screwworms are the larvae of a species of blowfly, and unlike most [00:04:00] fly larvae, they eat living flesh instead of dead or decaying tissue. That is fairly unique. And so these flies will come and lay hundreds of eggs near an open wound or another insect bite, or near a sensitive part, typically of cattle, like around the eyes or nose.

Perry: [00:04:23] And when the maggots hatch, they start eating the living tissue, which can lead to secondary infection and death. Uh. The screwworm was eradicated in the US in 1982, and over the following decade was pushed all the way south through Central America and past Panama. Uh, and that had been the state of play until 2024 when, uh, it re-emerged in Mexico. June 3rd, 2026. Just a couple weeks ago, there was the first case in the US, which was in Texas. [00:05:00] I think it's worth noting how we got rid of Screwworm in the first place. We used something called the sterile insect technique. So the screwworm flies. Uh, the women only mate once in their lifetime. The women, the females only mate once in their lifetime. Um, and, uh, they store that sperm and lay multiple clutches of eggs over, uh, you know, over the next months and things like that. But they only mate that one time. And so what the USDA had been doing is breeding these sterile male flies and releasing them into the wild. They would mate with the female and then that's it. The female will never mate again. And that was a highly effective, um, technique to push them back south. The problem is that there's only one sterile fly manufacturing facility operating right now it is in Panama and it can produce about 100 million flies per week.

Perry: [00:05:59] Estimates [00:06:00] suggest we need about 500 million flies per week to put down this spreading epidemic of blowfly. Texas broke ground on a new blowfly, uh, screw Screwworm sterile fly facility in April, but apparently it won't be ready until next year. Um, the state of infections right now are that there are 12 animals with documented infections, mostly cattle, but also a goat, sheep and dog. The FDA has given an emergency authorization for a drug called Nitenpyram, which is an over-the-counter drug for animals who are infected. Um, but, uh, the experts that have been talking about this suspect that there's many more infections than have been currently diagnosed, and this can spread pretty quickly and threaten the cattle industry. So, um, we're keeping a close eye on that. There is, of course, some politics here. It's worth noting that the USDA is the agency responsible for fighting this, and [00:07:00] between January of 2025 and January of 2026, 20,000 employees were lost from the USDA, both through layoffs and incentive retirement programs. Um, the the specific service responsible for Screwworm response, the Animal Plant and Health Inspection Service lost 25% of its staff. The administration says those losses are not a problem, and they have the spread of screwworm well in hand. I hope that is the case. Moving on, let's talk about Ozempic butt or Ozempic face and a new drug that might prevent it. At least that's how the headlines are reporting this.

Perry: [00:07:45] Um, Emily and I have talked before about, uh, this idea that the GLP one drugs lead to significant muscle loss, in addition to total body weight loss, and how that can give an appearance of sort of a gaunt face, which has been [00:08:00] labeled ozempic face. If you go back to our GLP one episode, you'll see that we point out that this muscle loss does happen, but it happens in any situation where there is significant weight loss, including, you know, gastric banding, gastric bypass, um, anything that's going to get you to lose 15 to 20% of your body weight in a year is going to result in some muscle loss because practically speaking, you're just not carrying as much weight around. You've got, you know, 20, £30 that every time you take a step you're carrying around and you'll lose muscle in your legs and your quadriceps in particular. So it's not unique to GLP one, but it does happen. Uh, but we now have a new study appearing in Nature Medicine examining a drug called appetite. Um, an appetite is an interesting. It's an antibody injection. It is an antibody to a protein called myostatin. Uh, the bodybuilders will know about myostatin. This is sort of [00:09:00] in the wellness space. Muscles produce myostatin and myostatin inhibits muscle growth. And so there is this sort of cycle where larger muscles produce more myostatin, which limits further muscle growth so that you don't become kind of too muscly.

Perry: [00:09:17] If you want to have some fun googling, you can look at some animals that are myostatin knockouts, including the Belgian blue cattle, which are like the most jacked cows you'll ever see in your life. I think there's also a whippet dog that is myostatin knockout. Um, that is, uh, like super ripped. And so of course, people are very interested in this kind of thing for humans. Abciximab was originally developed for people with some genetic muscle wasting conditions, but in this study, they randomized 100 people. Half of them got mounjaro and appetite and half just got mounjaro for a 24 week period. Both groups lost a significant amount of weight, as you might expect £25 in the combo group, £28 [00:10:00] in the Mounjaro alone group. Those weren't different statistically, but when they looked at lean body mass. So muscle loss, the group that got the combo, lost £3.5, compared to £7.7 in the group that only got Mounjaro. So that was a finding that suggested that indeed this combination, when given with GLP one therapy, might reduce some of the muscle loss. We see. Bad news folks, not FDA approved for any indication. You cannot get your hands on it quite yet. And of course, because it is a myostatin inhibitor, it will be banned by all the anti-doping agencies, which is, you know, as Emily likes to say, you know, it must work if it's going to be banned, I will say one other caveat, though.

Perry: [00:10:48] These people had a bit more muscle functional metrics like grip strength and chair stands and things like that. That test sort of how well your muscles work didn't show much difference. But, you know, this might have been too small [00:11:00] a study to look in detail at those things. Last one in our health news of the week is hard seltzer causing a brand new kidney disorder. Hard seltzers, like truly in high noons are becoming incredibly popular. Uh, I will say that I may have one or more of these in my local drink fridge at home. And so I was a little concerned when I saw a headline about a new kidney syndrome called Mahandra Vachharajani syndrome. That's a tough one associated with these seltzers. Um, what this is, is a series of cases of people who drank so much hard seltzer that the sodium level in their blood got dangerously low, a condition we call hyponatremia. The kidneys. This is an interesting the way this works. When you drink water, your kidneys sense that. And they make you pee more [00:12:00] water. So you. You know, if you drink some more, you pee some more. And it kind of. The kidney's job is to keep you in balance.

Perry: [00:12:06] If they fail to excrete the water you drink, that dilutes the solutes in your blood, like sodium and things like that, which are really important. And if your sodium gets too low, your brain stops functioning and you go into a coma and you die. Um, and that's not great. What is going on with these hard seltzers, at least in the cases that they're reporting, are people who are drinking, uh, you know, a dozen or more of these per day. And it sounds like to the exclusion of everything else. So as a kidney doctor, one of the cool things or interesting things about the kidneys is that they can excrete a lot of water, about 20l of water per day in someone whose kidneys work normally. That's you'd be drinking an awful lot 4 or 5, four and a half gallons of water a day to outpace their ability to excrete it. Although you'd be running to the bathroom a lot. But there is a caveat. They need either salt [00:13:00] or urea, which is a protein byproduct, to excrete that water. They don't need both, but they need one or the other, otherwise they can't get the water out. That's just the way the physiology works. And so the problem with seltzers like these is that they don't have any protein and they don't have any salt, right? All they are basically are carbohydrates and water.

Perry: [00:13:22] If people are getting protein or salt from other sources, usually they won't run into these problems. Although obviously drinking 12 hard seltzers a day can cause multiple other problems, including with your liver. Doctors listening to this will recognize that this syndrome, despite getting a new name, is not really new. We've known about this for hundreds of years, potentially. This is beer potomania with a different, uh, different name beer. Potomania was the a syndrome where people drinking a ton of beer got this hyponatremia, low sodium levels. And it's the same mechanism, you know, drinking a bunch of water, [00:14:00] not taking in any protein, not taking in any salt. And if you want a sort of less vice filled version, some little old ladies will get what's called tea and toast hyponatremia, where if they're only surviving on tea and toast, they're not getting enough salt. They're not getting any protein because toast and jam and stuff is just carbohydrates. They can also get hyponatremia. So don't drink too much. But if you do, make sure you're getting some salt and protein in as well, that is it for the health news of the week after the break. What's the deal with sleep? And we're back. Today we're going to talk about what's the deal with sleep. And to get us started, Emily, I'm going to play a quick clip for you from one of the greatest TV shows of all time.

Star Trek: [00:14:52] Truthfully, Jean-Luc, I've been entirely preoccupied by a most frightening experience of my own. A [00:15:00] couple of hours ago, I realized that my body was no longer functioning properly. I felt weak, I could no longer stand, the life was oozing out of me. I lost consciousness. You fell asleep. Oh, terrifying.

Perry: [00:15:17] What you were hearing. There is the great John de Lancie as the omnipotent being who transcends time and space, known as Q in Star Trek The Next Generation, he has temporarily been rendered fully human and has the experience, for the first time in his immortal life of falling asleep. And, you know, of course, Patrick Stewart as Jean-Luc Picard is wonderfully dismissive of him. But as I was researching for this episode, this kept coming back to me, this scene, because sleep is weird. It's maybe the weirdest thing that humans do.

Emily: [00:15:59] It's not just the weirdest [00:16:00] thing that humans do. So basically every animal has sleep or a sleep like resting state. So like dolphins sleep half their brain at a time so they can like keep one side of their brain awake and like, remember to breathe in the water. And then they sleep the other, the other side of the brain. And if you think about it, like it must be so important to sleep because it's so stupid, right? Like think about the idea, like.

Perry: [00:16:29] Really.

Emily: [00:16:29] Evolutionarily, this is the dumbest idea. Like we're going to evolve to like lay around for eight hours in a row Totally exposed to saber tooth tigers. They could eat us at any time. You would think you would select for the people who, like, didn't sleep, right? I mean, that's how evolution works. Natural selection eventually must be. We're getting something out of sleep and it must be all animals are. And yet this is actually, I think, still not super well understood. So we can't unlike with food where you can be like, here's why you need food. It powers the cell if [00:17:00] you don't have glucose, blah, blah, blah, blah, blah, sleep. We're just like, yeah, it seems.

Perry: [00:17:06] Clearly necessary. You know, the horrible experiments on animals where they keep them awake, they die. We still aren't entirely sure why you pointed out dolphins sleep half their brain. I mean, it's not just mammals. Jellyfish sleep like with a with a distributed nervous system. They go through these phases where they're like less responsive to stimuli. And then and it goes with the day night cycle. It's it is crazy. They're even single celled organisms that functionally sleep. I was trying to figure out like, what's the, you know, how would this thing even get started? And, and you can go back when we talk about evolution, you can go back into our very, very, very distant evolutionary past, like before animals even existed. There's essentially sleep because plants will photosynthesize with oxygen, but then also fix [00:18:00] nitrogen. And those two things are incompatible. They can't happen in the same cell at the same time. Like those chemical reactions just like won't work if you're doing both at the same time. So from the very first plants, they had to evolve this ability to like turn on the oxygen, like the photosynthesis thing and then shut that down and then turn on the nitrogen fixation thing. And so it would do photosynthesis during the day and nitrogen fixation at night. And it's everywhere.

Emily: [00:18:26] It's everywhere. We are sort of slowly, I think, understanding a bit better, like, what are we getting out of sleep? There's a sort of general idea that people will say, which is like, well, the brain cleans itself out. Like it's like your opportunity to clean things out of your, out of your brain. That's not very specific. There's actually some new evidence on mice from a couple of years ago where they looked at sort of the patterns of brain waves and basically found that like during the, the night, the brainwaves lined up in a way that were moving like debris [00:19:00] effectively out of the brain. And so their idea was, you needed this period of sleep where the brainwaves lined up in this way to like flush the byproducts of being a functional thing out of your brain and otherwise they just build up and build up and build up, and then you die.

Perry: [00:19:17] Yeah. These are you can actually visualize this was very cool set of studies like the, the cerebrospinal fluid, like the fluid that the brain sits in this, you know, sort of salty, clear fluid that protects it somewhat. Yeah. Just kind of like washing over the brain at night. That's of course, not the only thing that's happening to your brain at night. Like lots of stuff is going on. We'll need to get into some more detail as people start thinking about like, what's happening during sleep. But certainly for humans, it appears that memory consolidation between short term and long term memory is happening, probably primarily during sleep.

Emily: [00:19:57] I learned that from inside out. Did you see Inside Out? [00:20:00]

Perry: [00:20:00] Oh, I have seen inside out, but I don't I don't remember.

Emily: [00:20:02] Yeah. They like remember like when she's. Oh, they have the balls. They're like moving the balls from like the short term memory, like to, to the memory storage area. That seems to happen at night.

Perry: [00:20:12] I learned that it's important to feel my feelings.

Emily: [00:20:15] Yeah. No, that's also true. I cried so much at that movie. Oh my gosh, that's a great movie. You should watch that. Really good. Okay, uh, back to sleep. Okay, so people sleep. Big picture. Everybody sleeps, including potentially plants and certainly all, all, you know, living all animal like and an animal organisms. Probably it has something to do with cleaning something out and your brain is doing something. We don't completely understand it. People talk a lot about the idea of circadian, uh, biology here. So do you want to, and I hesitate to ask this because of some earlier episodes where you got too involved, but do you want to do a little of the biology? Doctor Perry.

Perry: [00:20:58] I think that people want to [00:21:00] hear about the biology people.

Emily: [00:21:01] Do people do.

Perry: [00:21:02] I believe.

Emily: [00:21:03] Okay.

Perry: [00:21:04] Do it. Um, briefly. No. Circadian biology is really cool. So circa around the day. So these this is the day night cycle which everyone on the planet earth has. Um, I say everyone, including the plants and everything like that. Um, we live on a planet that has a daytime and a nighttime, and it's no wonder that biology has sort of adapted to these, uh, to these, these different things. The way it works in humans is pretty cool. There's a specific part of your brain called the suprachiasmatic nucleus, which is the clock like to the point that if people have a stroke or a tumor in that part of the brain needs to get removed, they no longer follow day night cycles. They they just like free run through their circadian rhythm. The suprachiasmatic nucleus is the clock in your brain. And it doesn't only tell you when you're tired and when to go to sleep, but all the other things that vary throughout the day, [00:22:00] like your basal body temperature and your cortisol levels, that spike in the morning. And all of those things are determined by the suprachiasmatic nucleus. That part of the brain has a direct neural pathway to your retinas. And on planet earth, if you're human, the way the suprachiasmatic nucleus stays in sync with day and night is through light.

Perry: [00:22:23] It's very simple, and that's probably how you would design it anyway, right? Like, it turns out that if you put someone in an isolated room, right? Just like a no exposure to outside light whatsoever. You know, the lights on all the time or the lights off all the time. They have an inherent pace that their suprachiasmatic nucleus will follow. Some people have a slightly longer day than 24 hours, maybe 25, maybe even 26. And so if you just let them go and they've done these experiments where they keep these poor, you know, graduate students in, in like a lab for [00:23:00] weeks at a time while they, you know, write their thesis or whatever they pay them, but, you know, and they'll basically like go to sleep two hours later every night and they'll just, you know, by seven days later, they're all of a sudden 12 hours off. Some people have a shorter cycle, 23, 22 hours. And the reverse happens, right? They just kind of like every night they go to bed a little bit earlier than they would have the night before. So that's the biology. But we all fix that by seeing the day night cycle.

Emily: [00:23:25] Let me tell you that when I was in graduate school, one of my professors told me that when he was in graduate school, he actually tried to put himself on a 26 hour cycle because he thought he could get more work done. And it turns out that putting yourself on a 26 hour cycle does not work, even if your natural cycle, say, was 26 hours, because the light exposure means that your body is like not is going to try to get back to the 24 hour cycle. So he really messed, he really messed things up.

Perry: [00:23:53] Yeah. It is, it is super powerful. You know, going outside, seeing the sun really does entrain the suprachiasmatic [00:24:00] nucleus. Just to close the loop on sleep. The suprachiasmatic nucleus has a neural connection to the pineal gland. And the pineal gland releases the hormone melatonin, which, um is one of the important hormones in making you sleep, and is obviously also a supplement that many people use for sleep. So just a bit of biology.

Emily: [00:24:20] Emily just that's only that was that was so good. So if we have people who are just like sort of not exposed, we can talk about artificial light, But if you're living in the general world, most people will fall asleep a couple hours after sunset and and wake up around sunrise or a little bit after sunrise because of the, of the light. I'm curious, given that if we sort of step outside the artificial light, like sort of go back to a time we didn't have a lot of artificial light. If people are living in places where there's like sunlight all the time or darkness all the time, like the ends of the earth, uh, do [00:25:00] they sleep less in the summer and more in the winter? Is that a sort of standard adaptation? You know.

Perry: [00:25:06] I don't know, but let's Google and find out because it's a good question.

Emily: [00:25:10] That is a good question.

Perry: [00:25:11] Sleep times at extreme latitudes. Uh, heavily disrupted by intense seasonal light variations. Shorter fragmented sleep in summer delayed, often increased sleep durations during the dark winter night. Yes. You know, humans evolved in sort of equatorial areas of Africa. So we're that's maybe our ideal environment in terms of how much we should be sleeping. But of course, in the modern era, we're exposed to a lot of light sources that aren't the sun, which is one of the major problems people have in terms of, you know, staying on a good sleep schedule.

Emily: [00:25:41] These high latitudes, adapting your sleep in that way to the time of year is actually probably evolutionarily beneficial because in the summer, you need more hours to work. In the winter, you need fewer hours to work because it's too cold. So. Anyway. [00:26:00] All right. So in this modern world, we are we need to sleep. We know why we sleep generally at night. Uh, people like to measure their sleep, like getting back into the kind of like influencer wellness space. People are really, really interested in measuring their sleep. It's one of the core things that all of these, like trackers, uh, like to measure. And we tend to talk about three pieces of sleep. There is duration, which is how long we are sleeping. There is latency, which is how quickly we fall asleep. And there is efficiency, which is a metric of how much of the time you are in bed that you are actually asleep. Are there other measures that you feel like you care about? Those are the ones that my tracker likes to tell me about.

Perry: [00:26:51] I'm so curious how you do on your trackers because I have I have some theories. Um, I like, I suspect as an endurance athlete, [00:27:00] like I want you to have very good sleep parameters because I feel.

Emily: [00:27:06] Like I appreciate.

Perry: [00:27:07] I feel like that should be what you get for all the pain you're putting yourself through during the day is like a good night's sleep at the end of it. Um, in terms of other sleep metrics, I mean, I am interested in sleep stages so we can talk in a minute after I hear your numbers about the different stages of sleep and what might be happening in them. And I think there's interesting actually pathology in each stage of sleep that is worth mentioning. But talk to me about like as a real athlete, an endurance runner, I assume your sleep latency is 30s, right? Head hits the pillow, you're out, you sleep a solid eight hours and you're good to go.

Emily: [00:27:44] So I don't sleep as many hours as I should, but my sleep efficiency is very good. So my sleep efficiency is like 95%, which I think means basically I'm asleep all the time that I'm in the bed. But my my tracker thinks that my duration sucks. It tells me every [00:28:00] morning hours versus needed 73%. That's like a standard it thinks I should be. Yeah. Okay. So to be fair, my my whoop, I love whoop. I love you whoop. My whoop thinks that last night I should have been sleeping for nine hours and 28 minutes. But as a person with a job, I was unable to achieve nine hours and 28 minutes of sleep. I managed to get six hours and 52 minutes of sleep, which I think was actually pretty good. That's not like, you know, that feels like a solid amount of time. Um, but I, uh, it's now it tells me my sleep debt is one hour and 18 minutes and I feel like it's just going to, you know, anyway.

Perry: [00:28:38] Yeah, that's how sleep debt works. It just adds.

Emily: [00:28:40] It just adds up until you're dead.

Perry: [00:28:42] I think whoop, um, uh, here is probably like looking at your activity during the day and extrapolating, like how much sleep would be appropriate. And that probably isn't quite right. Full disclosure, uh, we ran a study for whoop back here several years ago. So I've received research [00:29:00] funding from Whoop in the past.

Emily: [00:29:02] How many hours did you sleep last night, Perry?

Perry: [00:29:04] I slept seven hours, which is sort of the standard for me. I mean, my problem.

Emily: [00:29:10] That sounds like a number that somebody reports. If they, uh, just estimate it and don't have a tracker or app on their phone.

Perry: [00:29:17] I mean, I can get, if we could pause the podcast and I can get my app out because I, I am wearing a Galaxy Watch. I don't sleep numbers, but I don't. I don't necessarily care that much. My problem with sleep is that I feel like I can't always sleep. You know, I have to wake up because kids need breakfast and all that kind of stuff. And high school starts way too early before the sun even comes up, which is clearly bad for your suprachiasmatic nucleus. But then, you know, there's some days on the weekend where I'm like, oh, I can sleep in, but then I don't. Like, I want to sleep until 8 or 9 a.m. and I still wake up at 615. And that bothers me. That's my, my sleep.

Emily: [00:29:56] Problem that I think a lot of people have that sleep problem. Okay, so it's not just how much [00:30:00] time you're asleep. It is what you are doing when you are asleep. And there are different stages of sleep. There's deep sleep, there's REM sleep, there's light sleep. Should I care about which one I am in? For how long?

Perry: [00:30:12] Yeah, I think so. I think so. Um, so let's go through a couple of them. So REM sleep, which is rapid eye movement sleep. That is what's happening when you're dreaming. And the thinking from the neurologist is that this is where a lot of that memory consolidation is happening that we talked about from inside out. So converting short term to long term memories. Rem sleep is a fascinating physiologic state. You may know that you're paralyzed from the neck down during REM sleep to prevent you from acting out your dreams. When this goes wrong, people do act out their dreams to kind of disastrous effect, as you might imagine. Check out comedian Mike Birbiglia's Sleepwalk With Me, which is a hilarious retelling of him literally like jumping [00:31:00] out a hotel window to escape from a missile that was like, locked on him in a dream and waking up, you know, covered in glass in the hotel parking lot. This is very rare, fortunately. But what's not so rare is sleep paralysis. And so you can actually regain consciousness during REM sleep. So you're sort of like, all of a sudden you're awake. Rem is very close to being awake actually, like in terms of brainwaves.

Perry: [00:31:27] And so you can open your eyes and still your brain has that paralysis function turned on. And the experience is you're lying in bed and you cannot move your body at all. And it's very frightening. And a lot of people will talk about like alien experiences or feeling like, you know, they're like demons and things like that in the room. That can be really disturbing. Rem sleep is inhibited by alcohol and benzodiazepines. And so insofar as it's an important stage of sleep, that is something to be aware of if you're drinking [00:32:00] at night. So that's REM. And then deep sleep is also important probably for that cleaning function that we talked about, the CSF sort of washing over the brain and getting rid of all the junk. There's weird pathology that can happen in deep sleep too. So that's the place where night terrors happen. This is distinct from nightmares, which is a REM sleep phenomenon. It's just a bad dream. Night terrors, if you've ever seen, are terrifying for people watching. It is. People will just scream bloody murder in the middle of the night.

Emily: [00:32:32] So it's like, just to be clear, this is like very common in kids and it freaks out parents because there is sort of nothing you can do. Like your kid is sitting up in bed screaming. And unlike with a nightmare where, you know, they, they are kind of a conscious and they'll be like, here's a badger. There was a monster chasing me. You could be like, okay, they're just screaming and screaming and screaming and there's nothing you can do because they're not really awake. They're just asleep. And all you can do is [00:33:00] kind of leave. And then they just lay down and go back to sleep, and they have no memory of it. But it's horrible.

Perry: [00:33:04] Yeah, really, really bizarre. As we said, if there's a theme of this episode, sleep is very strange and so weird.

Emily: [00:33:10] So weird.

Perry: [00:33:12] Again, clearly, you know, a physiologic state that leads you every once in a while, especially when you're a young child. To scream as loud as possible in the middle of the night is not good. If you're trying to hide from saber toothed tigers. So the benefit is clearly, clearly extreme.

Emily: [00:33:29] Let's talk about that benefit a little bit. So, you know, it's sleep is something where there is a a fair amount of research on, you know, why it matters. And some of it's in this very extreme, like animal stuff, you know, if you keep the animal up for some amount of time, it just dies. But we can also sort of think about at smaller scales, what is the impact of sleep deprivation, either a single night of missed sleep or a long period of time of more limited sleep. The best studied parts [00:34:00] of this, in my view, are cognitive. So not sleeping enough either skipping an entire night of sleep or sleeping less than you should in a kind of consistent way really impacts your ability to. Basically people's executive function, short term memory, any kind of cognitive performance. It also impacts mental health. It impacts depression, impacts all kinds of stuff like that.

Perry: [00:34:28] Absolutely everything gets worse when you don't sleep. And a lot of these things can contribute to something of a vicious cycle. So, you know, sleep deprivation can worsen depression symptoms. Depression can manifest as increased sleepiness, but also decreased sleepiness. It can it can go both ways. The same thing, you know, anxiety symptoms can worsen with lack of sleep. And then being more anxious can worsen your ability to fall asleep. So yeah, you can definitely get yourself into quite a bit of trouble here. The place that [00:35:00] I worry about this a lot, I mean, I worry about adults, but having a teenager actually having two teenagers in my home is are the kids. So, Emily, uh, are you as concerned as I am about our kids not getting enough sleep?

Emily: [00:35:15] One of my major concerns as a person is that kids are not getting enough sleep. And let me, uh, say more about this because I care so much about it. So and I think this is adults fault. So generally kids who are, you know, elementary school, middle school, high school, they need a lot of sleep. You know, high school kids need, you know, 9 to 10 hours of sleep, ideally a night. They just, they need a lot of sleep. And we are getting in the way of that in two ways. So one is with school start times. So high school tends to start early in the morning. It actually tends to start earlier than elementary school in many school districts. This is stupid because high school students are on a kind of delayed circadian rhythm relative to most people. [00:36:00] So actually, their ideal is to go to sleep later and wake up later. And we have seen when school districts move back the school start time so kids can sleep more. We see that kids do better in school and we see like things like less car accidents because they're just like a bunch of less tired teenagers driving around. So we're having a problem with school and the school start times.

Perry: [00:36:22] Yeah. Why is this like, I've got an elementary school kid and a middle school kid and a high school kid, and they wake up in the opposite order, like my elementary school kids up first. Yeah. So like, why is it why not? Yeah.

Emily: [00:36:35] Like I think it is.so I've, I've talked to many school districts about this. And the answer I often get is something about bus schedules, but it's hard for them to be specific about exactly what that, what that means. I think there's also an issue with high school sports. At the end of the day, kids need to go to a game. And so if school starts later and ends later, you're less time for sports. This relates to my second feeling about how adults are getting in the way of our children's sleep, which is putting them into many [00:37:00] activities. And actually, I think that hits even as early as middle school. People are like, okay, my kids got to go to like six hockey practices and, you know, rush and math school. And so then they're not going to get home until 9:00 at night, and then they still have to do their homework. Like, no, no, we need to actually treat sleep as a priority for our children. And understand that means they may not be able to do some of those other things. And that's okay, because sleep is important, not just like a nice to have. It's not a nice to have. It's like a need to have. Otherwise you die.

Perry: [00:37:31] Oh my gosh, I want there needs to be like a stop over subscribing your kids movement because there's so much social pressure here. Like all the other parents signed their kids up for 30 things. And like, if I don't sign my kid up for 30 things, then I clearly am not, you know, like, how will they learn Mandarin?

Emily: [00:37:51] But I think we also have an opportunity with our older kids to enroll them a bit in the sort of need for sleep and in actually thinking this is important and helping [00:38:00] understand, like helping them prioritize this too. Because of course, some of the things that get in the way of sleep are like, I'm texting my friends.

Perry: [00:38:08] Sleep is clearly important. Let's get to brass tacks here. Like, how much am I supposed to be sleeping is the best thing for me to do to strap something on my wrist and trust what it tells me. Can I like? Is it should I base this on how I feel? Is it just eight hours full stop? Like, what's your thinking in terms of just the amount?

Emily: [00:38:28] Generally, my sense is that adults need about seven hours of sleep a night. Uh, if you are doing a high level of activity, you probably need more. Um, there's small share of the population that need less, but most people need about seven hours at night there. Of course, there is variation in this. And I think the, the sort of standard diagnostic actually not so different from a diagnostic with kids is if you are sufficiently rested, you should not weekend oversleep. So you shouldn't be [00:39:00] tired during the during the day. But then also if given an opportunity, you should basically get up at about the same time. Like not exactly. You know, if you generally get up at six, like you. If you generally get up at 6:00 and like, you know, then on the weekend you get up at 630, like that's fine. But if like you're generally getting up at six and then you give yourself an opportunity and you sleep until noon, like you are not sufficiently rested. And I think that that can also work with kids. Like if you sort of see, you know, my kids sleeping until 3:00 in the afternoon, that does suggest that they are not getting enough sleep in general. So looking for that kind of signal for people can help titrate a little bit. Like do I, does it kind of seem like I'm hitting about the right amount?

Perry: [00:39:41] Fair enough. Um, plug for familial natural short sleep, a rare genetic mutation, which, uh, has people sleeping about 5 to 6 hours a night and being completely fine with it. You don't have this. If you are listening to this podcast, that's just the chances are, but you might come across it because it's very cool. Um, as we were doing this [00:40:00] episode, I even looked into it in a little more detail. And it is an evolutionary mystery. Like, one of the things that we're talking about that the people who study this, you know, syndrome, it's not really a syndrome because it doesn't cause any problems. But one of the questions they continually ask is like, wait, why hasn't this spread through the population? It's so clearly evolutionarily advantageous. So it may be that we're still missing something. Like we're not measuring something that is beneficial from sleep, that that even these miracle people who apparently don't need sleep might actually not be getting it. It's, it's hurting their reproductive chances in some way.

Emily: [00:40:34] Hear me out, hear me out. It may be that an evolutionary from an evolutionary standpoint, being awake while it's dark is actually not that helpful because you can't really do that much. There's like no light. It's not like you're like getting stuff done. And so there's not that much advantage and more time in bed is more time for sex. And so then you like, maybe by like being in bed for less time, you have less sex and.

Perry: [00:40:57] Okay.

Emily: [00:40:57] Okay, okay.

Perry: [00:40:59] So this is the [00:41:00] thing where it's like when you're married and one partner goes to bed earlier than the other and the other is like, no, no, no, I'm I'm going to like stay downstairs and play this video game or finish watching this movie. Like, that's not great for the old marital relations.

Emily: [00:41:15] Yeah.

Perry: [00:41:16] I'm sold.

Emily: [00:41:17] Sold. Okay, there you go. We solved that problem.

Perry: [00:41:19] Solved that controversy.

Emily: [00:41:22] Speaking of short sleep. I think it's worth talking a little bit. You know, if we sort of know how much sleep people should get, we know that one of the things that gets in the way of people's sleep is just I don't have time to sleep. And I often tell people like, like, but it is important. Like, even for adults, I think we can, we can treat sleep like it's a like a spa day or something, but it's actually a biological necessity. So like one of, you know, trying to figure out your life so you can get more sleep is good. But the thing that is really frustrating to people is when you try to go to sleep and you can't, or when there's some sort of biological thing. So the two big things here. So one of them is insomnia. [00:42:00] And the first one is sleep apnea. So a lot of sleep apnea gets in the way of sleep for a large number of people in ways that they may actually be UN be unaware of. So this is when we think this is going to affect the quality of your sleep. Less so than the than the sort of duration. It's like the realized duration.

Perry: [00:42:18] Let me I'm going to sidebar. Sleep apnea. Um so full disclosure sleep apnea sufferer here. Um, really I use it. Yeah, I do. I use a Cpap machine at night. And so, you know, a couple of things so massively underdiagnosed like it is. It is a huge problem. Some symptoms of sleep apnea. What you'll see on the sleep apnea scoring scales is how tired you are during the day. Like the classic symptom of sleep apnea is like, oh, I'm falling asleep at my desk. I'm falling asleep at a traffic light. You know, that kind of severe daytime sleepiness. There's a lot of other, more subtle things. Migraine headaches or recurrent headaches. Hypertension, uh, can even be caused by sleep apnea. And there's a host of downstream cardiovascular problems. I [00:43:00] was diagnosed, as many people were initially by my wife, who sleeps in bed with me and heard me snoring a lot and occasionally sort of stopping to breathe. If you do sleep in a bed with someone else, ask them about this. I think it's important to realize, like, you know, you, if you're just listening to this on the podcast, you can't see me. But there's a misapprehension, I think that that sleep apnea is exclusively reserved for people who might be overweight or obese. That is not true. There is increased risk in those populations, but it also has a lot to do with like the structure of your soft palate and like the way your your nose and your mouth and your jaw is put together. One of the first treatments I tried was actually this like mouth prosthesis that like juts your lower jaw forward, which actually works for my type of sleep apnea. But like, I woke up in incredible jaw pain every morning, so that didn't seem good. And then I just like buckled [00:44:00] in and got the little Cpap machine. And it's just like, it's a little thing that goes in it, like goes in my nose, only it's not like a full mask and it's super quiet and I don't snore anymore. And my wife is happier. We were like talking about, have you heard of sleep divorce?

Emily: [00:44:15] You were going to have a sleep divorce. We're going to have a divorce.

Perry: [00:44:17] Yeah. Sleep. Divorce is when spouses who still love each other very much sleep in separate rooms because of, like, sleep issues. And oftentimes it's snoring. Um, so all right, that's probably enough on sleep apnea, but like, do get yourself checked out if you think this could remotely be a possibility.

Emily: [00:44:35] Uh, the other thing is insomnia. So insomnia is pretty common. Um, of course, everyone experiences some kinds of insomnia. You know, like I had a stressful day. I can't turn my brain off. Uh, but kind of chronic insomnia, which typically means, you know, a consistent disruption of sleep, inability to get quality sleep over a period of at least three months for at least three nights [00:45:00] a week. That's about 10% of the population and insomnia can be really debilitating. People get very, very tired. It's also very, very frustrating. And often people will respond by trying to like go to bed earlier, but then you're like laying in bed for more hours. And then, you know, at the end of it, you're tired, which is affecting your mental health. This is really bad, like all kinds of sleep problems. So there is one really, really good treatment for insomnia, which is cognitive behavioral therapy for insomnia, which is like a standard package of, uh, of interventions that, you know, for a very large share of people who do them improve people's sleep. And it's kind of a set of things like, don't actually lie on your bed when you are not able to fall asleep. So, and, you know, reframe some of your thoughts around not panicking. Uh, there's a bunch of pieces of this that are, that are popular, but this is a very, very effective technique that [00:46:00] not as many people know about as should.

Perry: [00:46:02] Yeah, totally. And apologies, as a doctor here who has given the wrong answer to this question, like more times than I can count. So we have when people ask us about sleep problems, docs will go straight to sleep hygiene. And it's this. It's like, oh, okay, no screens before bed. Like, don't, you know, don't lie on your bed unless you're there to sleep or have sex and like, sleep in a dark, quiet room and keep the temperature cool, cool. And it's like these parameters around sleep, um, that are kind of easy to say and make sense. And they might offer some benefit, but actually looking into it, the randomized trial data about sleep hygiene exclusively for insomnia is pretty poor. It doesn't really work. So it's like, oh, put that phone away. Like actually it doesn't. It's not that.

Emily: [00:46:49] There's anything wrong with putting your phone away, but it's not really going to.

Perry: [00:46:52] Work. It doesn't really work. Whereas this cognitive behavioral therapy and there's, there's interesting elements of it. One of the ones that I hadn't thought of because it's [00:47:00] somewhat counterintuitive, but seems to work quite well. And by the way, this is delivered as a package. So don't, you know, look into this in a little bit more detail if you're suffering from insomnia. But one thing that came out was, you know, if you are normally falling asleep at midnight instead of, as you say, like getting in bed at eight and lying there for four hours, not able to fall asleep, get in bed at midnight so that your body and your brain, more importantly, is like, oh yeah, I get in bed and I fall asleep. And then you can kind of move that time back. So there are solutions, but we should talk probably about you said not enough people get access to cognitive behavioral therapy. And there are plenty of ways to access CBT. This is not just necessarily through a psychiatrist or psychologist. There's even apps that provide some of this support and information. But most people who are suffering from insomnia are going to turn to other things like drugs, supplements, medications, ET cetera. Emily, [00:48:00] what's your thoughts on on, on this, uh, this area.

Emily: [00:48:04] So I think that there are, there are two categories of how we think about substances and sleep. So there's one set of substances that are sort of category of substances that interfere with people's sleep, alcohol being probably the most commonly consumed. And for most people, alcohol, particularly close to bedtime, interferes with sleep. Uh, this is also true of, of benzos. So there's sort of that category of like, don't do that. Uh, if you are struggling with, uh, with sleep or at least recognize the, the impacts. And then there are these sort of sets of drugs that people take to improve their sleep, like melatonin or Ambien in more extreme cases. Uh, and those, you know, those can be effective. Melatonin is very effective for jet lag. And in particular, um, you know, for most people think that they would like to not be dependent [00:49:00] on medications for sleep, ideally, which is where I think going into something that actually fixes some of the sleep architecture in the first place is a, you know, a sort of first, best option doesn't mean there's not a place for some of these other some of these other things in the short term.

Perry: [00:49:17] Yeah. I think the dependency issue is a real one. Almost all of these substances, potentially with the exception of melatonin, do have some physiologic dependency. So Ambien and things like that. Certainly Benadryl, the benzodiazepines, even alcohol, you become habituated to it. And once you stop, it's just harder to fall asleep. If you've been taking Ambien and you stop Ambien, it's harder to fall asleep for a few days. When you're off of Ambien, it's not the end of the world. There's there's little with melatonin, um, in the, in the data, although probably melatonin, at least in adults for sleeping is not as effective. It does seem to be effective for jet lag to kind of reset that circadian clock, go back [00:50:00] to the pineal gland there. Um, maybe not so great in adults. And maybe that's why we don't see too much rebound when you're off melatonin. People will have heard of kind of an alarming study suggesting that the chronic use of melatonin in adults increases the risk of heart failure. I don't buy this one.

Emily: [00:50:18] No, this.

Perry: [00:50:18] Is still.

Emily: [00:50:19] Just this is ridiculous. It's ridiculous. It is reverse causality. Okay, so let me explain what is happening there. Like people who have a lot of trouble sleeping are at risk for cardiovascular issues, you know, because there's other things that are driving that because potentially the lack of sleep puts you at risk for some of these of these issues because sleep is so important. And so what's going on here is that people are having a lot of trouble sleeping to address their sleep issues. They take melatonin, and then there are negative cardiovascular issues which have to do with the lack of sleep. So it's like the lack of sleep is causing you to take melatonin and causing you to have heart issues. It is not that the melatonin is causing the heart issue. This is [00:51:00] like a standard reverse causality. Omitted variable bias. Something else going on. It is not a causal relationship and should not be treated as such.

Perry: [00:51:12] Yeah, yeah, don't freak out. But no, I love it. And I agree, you know. Bottom line, sleep is a thing that happens in the brain to the extent that you can retrain your brain, that's probably the best way to get better sleep.

Emily: [00:51:25] Agreed. Last thing I want to say is, do you think there's a space for these sleep trackers? Do you think that they help people? I'm not sure. We know. Like this is really just a generic question. I don't think we know much from from the data. It's hard to study that.

Perry: [00:51:40] It depends on the person. Um there there's a condition called ortho somnia, I think is what they're calling it now, which are people who get anxious about their sleep score, right? So like, they actually Paradoxically have worse sleep because they're like, oh shit, I've got to like, have my sleep latency be low. Like fall asleep, fall asleep, fall asleep. [00:52:00] If you are that type of person who's trying to optimize. Don't do it. Take it off. For many people, though, who aren't quite that obsessed with what the final score is, I think they can be useful in particular because some of those metrics, if you pay attention, really will show you how much alcohol in particular adversely affects sleep. I've had multiple patients who have used these things, and it's like I wasn't putting it together until my watch pointed out that like, my, my sleep score is ten points lower and it's on nights that I drink, it's ten points lower. And on nights that I don't drink, it's ten points higher. And something about that biofeedback can change the underlying behavior. So if you think that's for you, go ahead and do it. I wear mine at night, but I actually don't really know what. I don't pay attention to it.

Emily: [00:52:46] Yeah, I think this is an example where I would always ask people like, what are you going to do? Like, what's the information that you want? And what are you going to do with it? Right. So if you're going to like, if you're just going to like, look at your sleep score and feel good or bad or whatever, like that's not really very, very helpful. If [00:53:00] I just.

Perry: [00:53:00] Want to compete with others, I want.

Emily: [00:53:01] To. Yeah. If you want to win.

Perry: [00:53:03] Yeah.

Emily: [00:53:04] So I will tell you that my husband has an aura ring and I have a hoop. And because he doesn't want to see his sleep score, I have the aura app on my phone. So every morning I can see both my score and his score. Um, and that's marriage for you. Um, but I think for some people this the kind of feedback of like a little bit of sort of data, data collection, largely around alcohol, there's a few other things that are that are kind of common to, to people you can sort of see, okay, this is, this is kind of affecting me in a way that, um, that maybe would cause me to want to change, change my behavior.

Perry: [00:53:38] Sounds good.

Emily: [00:53:39] Perry, let's do the smash or pass. Smash or pass on. Sleep.

Perry: [00:53:44] Sleep. I'm smashing it, I love smashing. Let's do more of it. Uh, sleep is good. Emily, smash or pass.

Emily: [00:53:51] I'm smashing it. And I'm gonna. I'm gonna aim to get my hoop recommended. Nine hours and 28 minutes of sleep tonight, and we'll see. I'm going to be in such good shape tomorrow. [00:54:00]

Perry: [00:54:00] I'll see if I can email one of them about that algorithm.

Emily: [00:54:02] Yeah. Tell the tell the algorithm. Maybe a little, a little, a little aggressive. All right. When we come back, we'll do your question of the week.

Mailbag: [00:54:15] Hi, Emily and Perry. This is Lucy from Virginia. I'm curious about any possible benefits of eating your placenta. Is this something we should all be doing, or is it just kind of gross? Thank you.

Perry: [00:54:28] Okay. Uh, we've been we've been asked. It was only a matter of time. Emily should.

Emily: [00:54:33] For.

Perry: [00:54:34] Me. Should we eat our placentas?

Emily: [00:54:36] No, you should not. Uh, so, actually, some mammals do eat their placentas, and that's because there's not a lot of other food available. And if you have, you know, just say given birth out in some area where it's hard to access food. And again, you're a a not a person, you're a different kind of mammal. Like this may be [00:55:00] a good source of, you know, some nutrients. Um, but people unfortunately have access generally to other food and you should not eat your placenta because it's a medical product and there is no evidence that eating your placenta improves postpartum depression or does anything else positive for you. And again, it's a medical product. You shouldn't eat it fresh. You shouldn't eat it frozen. You shouldn't eat it, put in pills. There's just no reason to do anything with your placenta except say thank you very much for being an incredibly cool, interesting organ that allowed me to create a person. And in the words of Marie Kondo, you'll thank it for its service. And just like, let it go.

Perry: [00:55:45] I love that. What about burying it in your yard under a tree or something.

Emily: [00:55:52] Look, I mean, I wouldn't I wouldn't do that personally. But I think if you want to do that, that's fine. It's not going [00:56:00] to make the tree any nicer. But if you have a feeling like this is an important I have a sentimental attachment to this and I would like to remember it. And you want to bury it in your backyard like, yeah, sure. But I think you should be prepared. Like a coyote could dig that up and like, then they'll be like placenta all over. So you want to bury it pretty deep.

Perry: [00:56:20] Okay. With that, um, image, uh, we can, we can end, um, stick with us next week when we will ask, what's the deal with full body scans?

Emily: [00:56:36] Wellness, Actually is produced in association with iHeartMedia. Our senior producer is Tamar Avishai. Our executive producer at iHeart is Jennifer Bassett. Our theme music is by Eric Deutsch, and our content is for educational purposes only.

Perry: [00:56:51] If you like the show, help other people find us. Leave a rating and review on Apple Podcasts or your podcatcher of choice and help us spread the word about the show. [00:57:00] You can follow us on Instagram at pod. And don't forget, we want to hear from you. Head over to wellness.fm and leave us a question for our mailbag or suggest a topic for a future show.

Emily: [00:57:12] We'll let the influencers have the last word.

Sleeping Beauty clip: [00:57:16] Till then, sleeping beauty. Sleep on.