The Truth About Sleep with Matthew Walker

Many of my patients, and honestly myself, have difficulty getting good quality

sleep

. In fact, I would go so far as to say that, below back pain, the number one complaint I get is about insomnia, so today I have a very special guest, Matthew Walker, PhD, Professor of Neurology. and psychology at UC Berkeley, in fact he runs the center for the science of human

sleep

on Twitter. His username is Sleep Diplomat. He has a podcast on sleep, but it's actually very exciting because a lot of the facts he teaches in his books and his podcast focus on In fact, why we sleep, that's the name of his best-selling book which pointed me to his work. and I was very moved by this conversation.

We talked about the different types of sleepers there are, including early-rising night owls. The differences between the two. How Society. judge one versus the other, provide legit sleep tips that actually work and are backed by science, and we talk about this evolving field of sleep supplementation and sleep biohacking. I think you'll really enjoy this conversation and probably won't fall asleep. during the process, but you will definitely do it the next night. That's not a doctor. Point, it's a silly point. Let's start, what is sleep and how I guess we evolved to sleep. I mean, and well, actually, I'll take the second part first because it's fascinating.

When you think about sleep from an evolutionary perspective, it's the most idiotic of all human behaviors because you know that when we sleep we don't look for food, we don't find a mate, we don't reproduce, we don't care. for our young and, worst of all, we are vulnerable to predation and therefore, for any of those reasons, but especially for all of them together, sleep should have been strongly selected in the course of evolution, however What we have realized is that in every species that we have carefully studied to date sleep is present even in very ancient, ancient, uh, evolutionary species, what this means is that sleep evolved with life itself on this planet. and then it heroically worked its way through every step of the evolutionary path and if that is true it must mean that sleep serves an absolutely vital function;

In fact, it's once been said that if sleep doesn't fulfill a set of incredibly vital functions, then it's the biggest mistake the evolutionary process has ever made, and you know it now, actually 50 years old. great scientific research we realize that Mother Nature did not make a spectacular mistake in creating this thing called sleep, to begin with, in terms of what sleep is, it's a very good question, it's an astute question because most of us and I we would think this if it were not. a sleep scientist when we go to bed we lose consciousness and think that our mind is inactive and our body rests a little and that's it, we wake up in the morning so surely I can be missing some of this, is it really so important?

That simplicity hides an incredible complexity because sleep in humans is broadly divided into two main types: we have non-rapid eye movement sleep or non-rem sleep and we have rapid eye movement sleep or REM sleep, also considered sleep. dreaming, which is the The main stage in which we dream and non-rem sleep has been divided into four different stages, stages one through four, because we are a creative bunch as sleep researchers in terms of naming every second non-rem dream. -rem which is a kind of light non-rem sleep. Rem sleep three and four is deep non-rem sleep and your brain goes on this incredible roller coaster all night long, so when you go to bed tonight, you will first enter the light stage of sleep without repetitions and then in the deepest. stages and then you will stay there for a while and after about 50 or 60 minutes you will start to get up again and then you will have a short period of REM sleep, a period of dream sleep and then you will go back down, you will go back down to non-rem and until REM and that non-rem REM cycle runs in about 90 minutes at least in US humans is different for different species but what changes is the ratio of non-rem to REM within those 90 minute cycles .

As you go through the night, what I mean is that in the first half of the night most of those 90 minute cycles are made up of a lot of deep non-rem sleep and very little dream sleep, but as you you move into the second half of the night now that the balance changes and you have much quicker vision with much more dream sleep, REM sleep and very little deep sleep and the reason I mention this is because many of us will feel like you know The pressure of modernity and Modernity is desperately designed against sleep in many different ways, both through its stigmatization of sleep as lazy and also through work schedules, but what that means is that most of us, if Let's cut our sleep short, it's in those early morning hours.

You're getting up early to start the day, so you may be losing, let's say you know, 10 or 20 percent of your total sleep by doing that, but because REM sleep comes in the later hours of the night, you may be losing 40 percent. 50 60 percent of all your dream sleep, and as we'll probably discuss, your dream sleep is critical for things like learning to remember your emotional health. REM sleep is the time when all of us, men and women, release peak levels of testosterone, it's critical to our what we call endocrine health or our hormonal health, so I just want to paint a picture of the beauty and complexity of sleep. and finally knowing, by the way, that there is no one stage of sleep that is more important, you know. of people will say how can I sleep more deeply or how can I sleep more during dreams and I can understand that natural impulse.

It turns out that what we've learned is that different stages of sleep perform different functions for the brain and body. At different times of the night, they are all needed, otherwise Mother Nature would have removed everything unnecessary long ago. Are outliers seen in people who experience these stages of sleep differently, either with shorter intervals between each other or perhaps they are not used to them? Typical interval of 90 minutes for the entire stage. Oh, that's a great credit. You need to be a sleep researcher or take a gap year. It's a great question that deals with what we call variability, which is why you and I will probably be arguing.

Typical averages are for the average adult, but around that sweet spot of average there is a lot of variability when it comes to sleep. The first is in terms of sleep need and you know people like me have probably gone on record that you know I know this kind of sweet spot of eight hours on average and it seems to be on average about that, but the recommended range is between seven and nine hours of sleep, which represents two hours of variability. Some people can function perfectly well on seven hours and 15 minutes, others cannot, they need at least nine hours to function well, so there is variability in terms of total sleep time.

There is also variability in terms of the different stages of sleep. We know that genetically there is a certain predilection for being a more powerful and profound being. sleeper, so you'll kind of have a reason why we call it deep sleep is partly because the electrical brain waves as you go into stages three and four of deep non-rem sleep, all of a sudden you get these huge, powerful brain waves. slow and deep brain waves and depending on your genetic makeup and what you have been doing during the day and also your age, the size of those slow and deep brain waves is different, so there is also variability in the amount of REM sleep you get. people will have.

So, that's a very good point and then the bottom line is that there is variability in that 90 minute cycle, which is the average. Some people will have a consistent sleep cycle of maybe only 75 minutes, others up to, say, 105 minutes, so there is variability in that cycle. I know some people would listen to that and then try to engineer their sleep so that they wake up with this metronome-like quality to say "okay," so when I fall asleep, then if I patent those 90 minute cycles in 7 to 35 of the morning, that's the time when I end my life as if I should wait, it's not like that at all, this variability, yes, like that, biohacking hyper-optimization is very difficult to achieve, if not impossible, not only in sleep, would you say in most sciences, whether you're talking about nutrition, diet, mental health, there's actually no such thing as perfect because every time you strive to be perfect you create a host of other problems that you probably wouldn't expect, would you say What is the same for sleeping? about sleep biohacking, yeah, a lot, and I really accept what you're saying about um, you know, just biohacking in general, to me, biohacking, you still know, I think it's interesting and I think it's good for us. explore with pharmacological technology what aspects Can we bend in terms of some of the rules?

I doubt there's anything we can break in terms of the rules, but I also realized that it's probably arrogance of us to think that in the short term of our lives we'll be able to create something better in terms of sleep need and sleep schedule than something that took mother nature over 3.6 million years to evolve and when you fight your biology you know, let's say you're trying to optimize your sleep in these Ultra Short Cycles, sometimes it's called the Uberman cycle, where you do these 45 minute stretches and then you're awake for 90 or many variants of that.

What we found is that the evidence is very clear that the type of sleep is associated with poor mental health outcomes and poor physical health outcomes, so you know that sleeping like a baby as an adult is just an idea and that It's what the human schedule is in some ways, but in general I think when you fight biology and the natural tendencies of how we've been designed, you could argue that biohacking is a part of what you normally lose and the way you You know what you've lost is illness, illness and ill health, so I try to stay away from it, but that as a banner for the Silicon Valley people who constantly promoted, yeah, well, living, you know, here, you know, in Berkeley and not too far away, and I have a lot of different feet in those different worlds of tech with sleep, of course, um, so it's something that you know I work on.

I work a lot and I think a lot and I work with companies and I have some startups of my own that are trying to think in those ways, but always with this deep reverence, this incredible respect for the process of how we have evolved and unintentionally. going forward with that arrogance absolutely, that's such a smart approach, it's really refreshing to hear because a lot of times when you have experts on a certain topic, they quickly want to change everything or find that shortcut, so it's good not to do that. look at the approach from the other side of the spectrum, you know, we talked about the differences in deep sleep, REM sleep, intervals, there are also differences between people who prefer morning and evening and then maybe also in terms not only from hours of sleep. but the time of day in which you sleep there is and that is a second really important characteristic of sleep, which is that it is not only about the amount of sleep you sleep in terms of hours, and also another important characteristic is the quality of the dream. which we can go back to, but one thing many of us forget is the timing of our sleep and this comes back to a biologically well defined concept called chronotype.

So are you a morning and evening type or somewhere in between and depending on the data? It is approximately a third of the population. I should probably point that out before moving forward so no one thinks I'm biased in what I'm about to say. Unfortunately I'm like the rest of my pedantry in terms. of personality I'm desperately boring I'm completely vanilla I'm neutral I'm kind of an 11 to 7 kind of guy um but your chronotype as to when you want to go to bed and wake up is not your fault and it's not your choice because it turns out it's genetically determined and now we know that there are at least nine different genes that will dictate your mourning preference versus uniformity in terms of being a sleeper, what we call whether you're a night owl or you're a morning lark um and it's given to you at birth, it's programmed and it's very difficult to change and the reason why this is important from a practical perspective is for people to know and by the way, if you want to really know what type you are, you can go online. and you can look up something called meq or you can type it in, which means morning and evening questionnaire for chronotype and it takes about three or four minutes, it's really easy and you get your type.

You can also do it quickly. I can only say: look, you know, if you or I were on a desert island, there was nonothing to wake us up, because we could go to bed when we really wanted to and when we really wanted to wake up, instead of when society forces us to go to bed. and wake up, what time would it be? And for most people, that time as to when they would like to go to bed and wake up is very different from the time they are actually trying to go to bed and trying to wake up. suggests that modernity has driven a wedge of misalignment in terms of our sleep schedule based on our chronotype because society is desperately oriented and biased toward morning types, you know, it's this, early bird, catches the worm, those are the people who are praised for it. left out in the cold and punished unfairly, like it's their choice, the afternoon guys and the early bird get to catch the worm, but I'd also say the second mouse gets the cheese, so you know, there's many ways we should be much kinder to ourselves and to each otherIn society regarding the night types, the practical part is about people who I will see in my sleep center here who will tell me: look, I have an insomnia terrible.

I have difficulty falling asleep. I go to bed and I'm wide awake. the first hour I simply can't fall asleep and then I ask them a little more about their chronotype and it turns out that there is someone who on the weekend would finally go to bed normally around midnight 1am but during the week because of their schedule, of course, and it's It's understandable that they force themselves to go to bed at 10 p.m., which is a two to three hour difference from their natural chronotype, so it's no surprise that their biology isn't yet ready to try to help them sleep. the dream. but you're sitting in bed just willing it to happen and you can't just wish the dream to happen and do it, it's not like a light switch in that sense and so it disguises itself almost as what we call a form of sleep onset insomnia.

There is also something called sleep maintenance insomnia. Do you have trouble falling asleep or staying asleep? By the way, they are not mutually exclusive, but people with a chronotype who are night owls can sometimes have that challenge of being in bed as well. early and can't fall asleep, that's probably one of the most important points to discuss today because, as a primary care physician, obviously insomnia, whether it's early sleep or interrupted sleep, not being able to fall asleep after wake up in the middle of sleep. night um, it's easy for me as a doctor to look at, it's just a lifestyle change, talk about sleep hygiene, discuss caffeine use, alcohol use, things that would affect sleep from my level of training and maybe even my mental health, so it would be a step further. which most doctors probably don't even make it into their 15 minute visits, unfortunately in our current healthcare system, but should we as doctors be thinking more about chronotype?

I think we should certainly ask that as part of the equation and be sensitive. To that, in terms of understanding, it turns out that there is a whole field of chronobiology and chronopharmacology because, as we have now begun to understand, medications can have different potencies of effect based on different times during the 24-hour cycle. and there may be more or less potent times for you to provide that medication that you know, sometimes for hypertension medications. some evidence that time of day matters. There is a large field showing that anticancer drugs may have a non-trivial chronotypic dependence in terms of their efficacy.

So I think that's important. You also know I love the way you think about not just going to sleep hygiene, which is critical, and taking into account alcohol, which is not a friend of sleep, and caffeine equally, and then moving on to health mental. because what we know is that perhaps one of the most important common central pathways through which your body instigates this thing called insomnia is having an overactive fight or flight stress system within the body that is part of your automatic nervous system, it is calls nice. The nervous system is anything but sympathetic, it's very agitating, aggravating, it's the fight or flight branch along with something called the HPA axis, which is part of your hormonal axis, particularly in regards to a hormone called cortisol, which is a hormone related to stress and when those things are activated.

High levels of anxiety, worry and stress make sleep almost impossible and result in people experiencing the phenomenon that I would describe as tired but wired, where they are so desperately tired, but from a mental health perspective, they are so tired. Their point is that they are so wired that they can't fall asleep and until they really address the treatment of the mental health component, it will be very difficult. I mean, one could just offer you sedative sleeping agents that you know to try and get rid of the crust, but we know that there are better and better ways and I think one of the things that doctors have maybe started to do is become aware of the alternative currently recommended to sleeping pills, which is something called cognitive behavioral therapy for insomnia or cbti for In short, I would say that for any dream, I feel sorry for any general practitioner, any GP who faces a patient who says he has trouble sleeping, at first tries to direct him toward cognitive behavioral therapy for insomnia and try to find a provider for that.

I know it is difficult, but if we look at the number of people who can provide it, there is a mismatch between demand and supply, there is not enough supply for the demand, however, it is essential to know cognitive behavioral therapy for insomnia . Now there are some applications. which you can also use to help with that and make it more convenient, that's the only thing I would add to that equation, yes absolutely, I'm a big proponent of CBT. I have even been able to institute some introductions. I wouldn't say they're introductory sessions, but maybe, um, basic knowledge that I can pass on to my patients until they can see a mental health provider about how it works, where we work on thoughts instead of feelings, because actually the mind connection -body is There are so many connections that we give credit to the fact that patients are often ready to receive a physical diagnosis and are surprised or even surprised when everything comes back normal, the images, the lab tests and only until we arrive We realize your mental health.

That's where the problem at least starts and then shows itself powerful. You know think you know a doctor these days and I know I'm not singling out anyone. The job you have is immensely difficult. Inside these tablets. zip file periods of time in which you are supposed to go through this complex biological organism in front of you quickly make a diagnosis understand the treatment route the result prescribe and gain knowledge so that someone like you can already think about cognitive therapy- behavioral and then give them the building blocks to help them on their journey as they begin to seek more.

I mean, how much better would the world be? You know, if that were a more common practice. I can't imagine it. I think it would improve health outcomes. Significantly, that's why I'm a big advocate for increasing funding for primary care because the struggle that many doctors have are those 15-minute visits with patients they don't know and have no history, like urgent care. Model of care where a patient goes to see a doctor they've never seen before and somehow in 15 minutes this doctor is supposed to create a relationship with this patient, learn about their condition, their symptoms potentially related to some type of cause, create the treatment, make sure the patient understands the treatment that they can afford the treatment that they have access to the treatment and then document the entire interaction in 15 minutes on what planet and then make sure that insurance approves that Right, do you know what we do?

What are we doing if "If our goal is to try to help other human beings in the most medically sound way possible, then you are, I mean, heroes, keep doing that and thank you for what you do, thank you, I appreciate you saying So, for patients who are struggling to fall asleep, which could potentially be a different chronotype, is there anything you should recommend to those patients about changing maybe their job, maybe the hours they sleep, to what they should be? come up with this or should I look at a pharmaceutical approach for those patients? What's your recommendation?

I'm not really a doctor, but, you know, I think certainly the idea of ​​moving to medication for that situation could be. There are a few more steps along the way before the above low-hanging fruit is achieved. One would be to see how we can try to move their schedule even just a little bit and now post-pandemic schedules are never more flexible. People have incredible control or much more control over their own schedule, so trying to see if you can prioritize that as best you can would be ideal so that you yourself sleep in harmony with your chronotype instead of not matching or being out of sync with it. their chronotype, so I think making people aware of it, first of all, most people are not even aware that there is something that you know, a chronotype and how it impacts, and secondly, a Once they realize it, this is real and you can and will do something about it.

As a result, I start to sleep better. I think there are ways too, although people have tried to make evening types more like morning types and it's very difficult because it has a genetic basis, but you can help yourself, you can start to really try to limit your caffeine in the second middle of the day and mix it at night, try to stay away from alcohol at night again. I don't want to be a puritan. I'm not here to tell anyone how to live their life and life is for living, but Just keeping that in mind, the other thing is to try to really reduce your light exposure, so if you're a night owl and you're forced to Go to bed earlier otherwise you would start telling your brain that it is night. because we are a darkness deprived society in this modern era and we need darkness at night to release a hormone called melatonin which helps with the regulation of our sleep schedule and that is why for night types it is so important and in fact, The recommendation for everyone except particularly night owls who try to go to bed earlier would be in the last hour before bed, turn off almost all the lights in your house and of course stay away from screens, but that is not enough and what you will find is that reduction of light at night.

It will be surprisingly soporific, it will help you feel sleepier and more tired because most of us are in this electric light glow at night, then we turn it all off, crawl into bed and hope to sleep, and that's not going to happen anywhere either. terms of a transition, so darkness at night is great, then use eye masks, earplugs, blackout curtains, and finally cool your room because your brain and body need to lower their core temperature by about degree Celsius or about two or three degrees Fahrenheit for you to fall. they sleep and then they stay asleep and if you look at the chronotypes of people who are particularly night owls, the drop in their core body temperature doesn't start to go down until the early hours of the morning, you know, until midnight, 1 a.m. m., but still go to bed at 10 when your core body temperature is not at its impressive drop in promoting sleep, so having a really cool room somewhere around 65 degrees will also help in that. sense, so those are a number of things that you can try to recommend and you know?

Before one starts moving down the path of maybe thinking about pharmacology, I have two questions, the first is moving into these different chronotypes, when we talk about someone who is a gentleman chronotype versus a morning chronotype, how much difference is there between the recommended ones? Time to go to sleep, are we talking? Are we saying those people would prefer to go to bed at 6am? m. or there is a two hour difference between 11 p.m. m. and 1 a.m. m., as you said, it's actually a gradation and so, although I classify having mentioned these three groups, sleep science has now gone even further and divided it into five groups so that you can be an extreme morning guy. 8 p.m. m., which is quite noticeable in some respects, while extreme night types may not want to go to bed or even be ready to stay asleep until 3 a.m. m., maybe even 4 a.m. m. in the morning, so that's a big difference and then between those kind of finer and more fine-grained separations, the difference will start to get closer and closer and as a consequence it will be less extreme, but the distance between those two can be huge andthat can sometimes be a problem, you know if we will see this also in In couples who have very different chronotypes, it can obviously be a very challenging situation because one of them goes to bed at 9:00 p.m. at night and then the other goes to bed three hours later, just like the other person.

Now they're three hours into their nice deep sleep cycles and they're breaking up and then the morning comes, now the early bird they're awake at, let's say you know, four or five in the morning and the evening guy is now on the first half of the Deep Sleep cycle ends and then they wake up, so there can be a real challenge depending on when that imbalance occurs, it's very, very different, but I would say it's more of a gradation, in some ways. that you just definitely categorically are two hours different than this person is, that makes any sense Mike, no, absolutely, it's a sleep spectrum, yeah, um, the worry I already have in my head predicting having conversations about chronotypes with my patients is that they will be quick to label themselves as a specific type of sleeper and eliminate recommendations about sleep hygiene or anything they might be doing wrong or what might be going on with their mental health and assume it's because they just don't. are of this type and it becomes a self-fulfilling prophecy.

Is there a way that in the research this was controlled for, these people weren't just the ones who lived healthier lives or had higher levels of anxiety outside their home? control and it turns out that they sleep late or is it this genetic link defined here yes, it is a genetic link defined and you can see it in animal studies that you can manipulate those genes and you can causally force the animals to become, you know, a different type of cicada , what we call cicada, a 24 hour rhythm, um, so it's definitely causal in terms of manipulation, um, I think that's super, by the way, when If we look at those cities, let's say the night guys don't sleep as much As well as they could, it is linked to a significant number of poorer health outcomes in the market.

High risk. Night types will be at high risk for diabetes. A notably high risk of depression. risk of cardiovascular disease high risk of being tall having a higher BMI or being obese there are a number of associations here and you can control for those things by plugging in what you know lifestyle age smoking history exercise history and those associations usually still hold and I would Let's just say that the sleep hygiene recommendations you provide in many of the sleep tips we've received regarding optimizing and improving your sleep are applicable whether you're a morning or evening type, they're effective in both. types, so it really is important that you can modulate your sleep habits and your beliefs about sleep; in other words, what we call sleep hygiene if you want to try to get the most out of your sleep, no matter if you're an evening type or a morning type, if you're a night type, be aware of it, try to think about it, be aware, try to modulate a schedule, but don't ignore those other things either, just please don't feel like you need to be. fatalistic about it, well I'm just a nocturnal type and that's me and I'm doomed in terms of my sleep you're not doomed at all there's a lot of interesting things you can do I wonder maybe you can point me to a study like this exists we know, I guess, in our literature that those who work night shifts and develop shift work disorder or just work night shifts, have worse long-term health outcomes, um, yeah, now I'm wondering if that's true for those.

Who is a very extreme nocturnal chronotype? Would you still see those negative results? It's been studied a little bit and it seems that there is a certain degree of reduction now it depends on the night shift work because you know, if it is one hundred percent out of what we call out of phase, where you work at night and try to sleep during the day, even if you are an extreme morning type or extreme night type anywhere. of that Spectrum your sleep is going to be much more difficult during the day because we are a nocturnal species, we are designed, sorry, we are a diagonal species, so we are designed to sleep during the Nocturnal type of phase that night. phase, so it doesn't matter what it's going to be a struggle, but let's say you're working, you know, the early morning to late afternoon phase, so you have to wake up at 2 a.m. m. in the morning. or 3 a.m. m., that's a lot easier if you're an extreme morning type because you're much closer to what we call typical sleep offset, in other words, your wake-up time, whereas if you're an extreme evening type and you're working .

That shift is then much more difficult, but if you are required to work from mid-afternoon to early morning, now the opposite is true, which favors night owls because they don't mind staying up until two and three in the morning. morning, while for a morning guy likes to go to bed at 9 p.m. m., staying up until two or three isn't the same, it's like asking an evening guy to then stay up until 9 or 10 a.m. m. in the morning. even that is too extreme for them, so there is an adaptation that can occur depending on the chronotype and it has sometimes been suggested that now you can't do this legally or ethically of course, but shouldn't we ask people about their chronotype? and see if we can better assign them to jobs that fit more corona type now that I'm asleep, you know, perfectionist and in an ideal world that would be the case, but you know, I think there is some reasonable cause for something like that, would that be reasonable? change the way we think about shifts, maybe instead of a night shift and a day shift, we have a midnight shift, an afternoon shift, instead of, you know, midnight to noon, you have from 3 a.m. m. to 3 p.m. m., would that be more effective? for most people then it's a very good question: how should we best structure shift work based on what we now know in terms of harmful outcomes?

People have studied this and studied it very well. I have studied it in depth and I think what the evidence really points to is that, first of all, you should not alternate between extreme schedules very quickly, so you should not do two or three days of night shifts and then have a day free and then change to four days of day shifts and then change residents to three night shifts, which is residency, you know, that's shockingly bad, you know, it's torture for your biology, instead, the idea It's, first of all, that you should do longer stretches of one thing and then take one break then longer stretches of the other and then go back and forth at a much more glacial pace.

The other idea, which I think is even more nuanced and clever, is instead of doing these blocks where you're either doing the day shift OR you're doing the night shift, instead you just rotate people around. of the 24 hour format, so now you know that you start doing the afternoon and evening shift and you do that for a while and then you go from the afternoon to the early morning. I suppose it would be the case to switch to the middle of the night shift and then go from the middle of the night to the mid-morning hours and then continue cyclically like that, that seems to be a way that maybe you can adapt better or acclimatize better, although in Ultimately you just can't, there is no way you can be a human being in the space of 60 years of work, shifts that are not going to accommodate because, again, there have been millions.

There are many years of biology in terms of evolution that have designed our circadian rhythm and it is very programmed and very innate. Yes, I'm curious. I'll get over it like this because if you have the circadian rhythm, which is what I guess my knowledge is. What a chronotype is would be based on your circadian pattern. How did this wedge come to exist? Is there an evolutionary benefit to this wedge of chronotypes or is it a mistake on Mother Nature's part? We don't think it's a mistake and I think I've written about this before and other people have talked about it before.

I think it could be a very elegant design by Mother Nature to outsource the threat we face when we are unconscious for eight hours. What I mean by this is that we as humans. It's us, if you look at our history, we didn't normally sleep alone or in pairs, we actually slept in groups, so we normally slept in groups as a tribe and if you think about this now, each of those individuals in the tribe is going to be vulnerable at night for eight hours if we only assume eight hours, however, as a group as a collective, if there are some people who go to bed, you know four or let's say, you know three hours before and then there are other people. that they go to sleep three hours later, so they just took that eight hour window of vulnerability and now, as a collective, there will be people who will be awake for the first three hours and will continue to be night owls and then people who go to sleep will you will wake up earlier and be awake for the last three hours of the sleep phase, so now you as a group, Collective, have the first three hours of sleep covered, so you, as a group, as a collective. maybe they're just all sleeping at the same time for maybe just two hours a night, so mother nature compressed the threat period threat from eight hours to two hours by creating this thing we call chronotype variability, that's very interesting.

Who knew that nature was like a natural member of the hospital staff and making sure there was always someone to take care of the patients? Yes, you absolutely know that mother nature in terms of a scheduling administrative function is absolute perfection. Yes, it's a shame that life is so complicated and complex. and so many things change that it can never be as perfect as the design, but wow, sleep is obviously very exciting, well, you know, talking about getting enough sleep, what happens when we don't? In your book you talk about Alzheimer's, we talk. on physical health outcomes, can you shed some light on that?

Yeah, you know, I think 50 or 60 years ago we used to ask ourselves why we sleep and back then maybe the useless answer was that we sleep to cure drowsiness, which doesn't make sense. equivalent to saying "well, you eat to cure hunger," that tells you nothing about the nutritional benefits of foods, but now, after 50 or 60 years of remarkable research by all my colleagues, we have had to change the question and instead we have had to ask if there is any operation of your mind and if there is any important physiological system within your body that does not improve wonderfully when you sleep or is not shown to incur when you do not get enough sleep and the answer seems to be we do not know. the number of people who, say, could survive on less than six hours of sleep a night without showing any brain or body deterioration, rounded to a whole number and expressed as a percentage of the population is zero, yes, and what that tells us is that sleep is non-negotiable, unfortunately it is not an optional lifestyle luxury, it is essential and when you look at unhealthy health outcomes, first of all, you could look at hormonal health and we know that men who get a limited amount of sleep, Let's say four or five hours a night for a week have a testosterone level that is that of someone 10 years older than them, so lack of sleep will age a man a decade in just one week in terms of hormonal health, you see equivalent deficiencies in women in terms of luteinizing hormone, estrogen, follicle stimulating hormone or we can look at what we call the metabolic system and what we have found is that again, after a week of short sleep, let's say five hours per night, every night, your blood sugar levels are so off that Someone like you, your GP after doing a blood test, would actually classify you as pre-diabetic and that happens with what we call people who are normative. in terms of glucose profile, but after a week of bad sleep they are in On the road to diabetes there is another example that I think I will give often, which is more extreme but also more subtle: the global experiment that is carried out in many of us (in fact, around 1.6 billion of us in 75 countries).

This is done twice a year and it's called daylight saving time and there was a surprising research report that showed that in the spring, when we lost just one hour of sleep, there was a 24-fold increase in heart attacks, the risk relative to the day next, but still in the In the fall, when we sleep an hour, there is a 21 reduction in heart attacks, it was bidirectional and now we have found a very similar pattern during those transition periods for things like traffic accidents on our streets and even suicide rates. In fact, I think these are examples.

You know, there's another big study that looked at the immune system and what they found was that a night of just four hours of sleep reduced critical cancer-fighting immune cells that we call natural killer cells. reduced them toby 70 percent, which is a fairly rapid state of immunodeficiency after a bad night's sleep. No, you know. I offer this scientific evidence to support the case that it's critical to health, but I also know that in doing that for those people who have difficulty sleeping, do you know how you balance that tension as a public communicator? Because now I don't want people to get even more stressed about the sleep they're not getting, so please, if you're struggling with sleep, first turn off my voice, are you going to stop and stop listening, uh, I'm sorry for the views and clicks, um, but the second thing is look, everyone has a bad night's sleep, even me and me.

I've also had bouts of insomnia throughout my life, you know, a bad night's sleep is okay, it happens to all of us, don't worry, don't be scared, don't get too anxious, but if you have persistent difficulty sleeping . Go see your doctor and ask about help for insomnia and particularly cognitive behavioral therapy for insomnia, but I just want to make that clear. I don't want to be triggering. I don't want to be alarmist. I just want, I want to build. the case the evidence-based case for sleep without you necessarily knowing that it worries people too much. I think that's a very important point because the interesting thing about not getting enough sleep is that it damages your mental health and then if you have problems with mental health, that damages your sleep, so you're in this cycle where, if we talk constantly about not getting enough sleep and how dangerous it is, it can actually harm your ability to sleep well, that's exactly the irony that is and we've seen We've done a lot of work on sleep and mental health over the years. .

I think one of the surprising findings that we found was that in the last 20 years we have not been able to discover a single psychiatric condition in which sleep is normal and I think that tells us everything we need to know about the relationship, the intimate relationship between our sleep health and our mental health, our emotional health, and it's bidirectional what we've discovered is that if you and we published the city a few years ago showing that if we take perfectly healthy people who don't have any signs of anxiety disorder and the We deprive ourselves of sleep for just one night, almost 50 percent of them the next day classify as having an anxiety disorder because their anxiety has simply gone through the roof and we find out why, because there are emotional changes within the brain, these centers of Deep emotional anxiety are just erupting in terms of their sensitivity and their reactivity, so insufficient sleep can cause anxiety and there are causal causes.

There's evidence for that now, but also having anxiety can lead to worse sleep, so you know that poor sleep equals poor mental health, but separately, poor mental health can equal bad sleep at night and when those two things start almost like two, you know two. Bad kids conspire together, it becomes this vicious cycle of a self-fulfilling prophecy of worse insomnia, worse sleeping difficulties, and, if that's the case, worse and worse depression or anxiety, which simply compounds the problem, highlighting the importance of the cbti that we can offer to our patients. right before I ask my last question, this is more of a curiosity that I've had and I've sort of blamed it on the sympathetic nervous system that drives us when we don't get enough sleep to be able to feel awake, but then when I guess let me ask you ask and I'll give you my theory and you tell me how wrong I am um yeah, why my patients?

And I guess I've also experienced this myself when, uh, if you're going through a period where you're not getting enough sleep, sleeping five hours a night and then you have a night where you're sleeping seven or eight hours or whatever. If you have the right sleep pattern for yourself, you feel more tired the next day than if you had to sleep. to five six hours, isn't it fascinating? And although it's been less scientifically documented, it's so common in terms of anecdote that I think it's very clear, you know it's kind of like when you look at Amazon user reviews and you see.

We know that 30,000 people have given it a rating of 4.9. You have to think that it's probably a good product. When that number of people in the general public say that this is happening, you have to believe that there is something in it that we What is happening here is that every night, when you don't sleep well, you are accumulating what is called a sleep debt and your body understands its sleep debt. Now, in part, sleep is not like the bank, you can't accumulate debt. and then expect to pay it without consequences. um, however, the body and the brain will try to catch up on some of the sleep they've lost, so let's do the extreme example.

You know, I take you tonight and deprive you of sleep for eight hours and then give you all the recovery sleep you want the next night and the next night and even the next night, will you sleep more those next nights? You will absolutely have what is called a sleep rebound, but will you get all the recovery sleep you want the next night and the next night and even the next night? eight hours of sleep you've lost isn't even close, you mostly make up 50 of that lost sleep; In other words, you can offset part of that debt but you will never be able to pay it all, but the interesting thing is that as you are paying it is because you have accumulated such a heavy debt, such a great weight of drowsiness and sleep pressure after two or three nights of bad sleep, then you sleep soundly, you have that sleep rebound effect and why you have fallen so deeply asleep the next morning, when you wake up, you have something called sleep inertia, almost like sleep drunkenness and, as you describe it, you almost feel worse as a result, now that's just the process of your brain and your body telling you, first of all, great, you had a great night's rest. but second, we're not done yet because you still need a few more nights to eliminate some of that lingering debt and the grogginess and sleepiness you feel is still a reflection that you've cleared some of it, but by no means all of it. of that and your brain was actually still hungry for more and still wanted more, you're just going to have to wait a few more nights before you get it back, but as we all naturally think, okay, it was that night, but why am I?

Still groggy, why am I still sleepy the next day? We never thought of sleeping as if you had this kind of schedule, you know, day after day, night after night, we think I had a few nights of bad sleep. I should be able to do it all in one night of recovery and I wake up feeling like the Energizer Bunny, it takes longer than that, that makes something do it, eh, doesn't answer my question, but why if I slept for five hours and didn't I would restore my sleep, wouldn't I feel? So tired is it because I didn't go into that deeper sleep, so there are two possible reasons: the first is that you will still have gone into that deep sleep, um a lot, but you won't have slept as much, so you won't have had as much kind of inertia. , means something transcendental, having that effect the next morning.

The other problem is that yes, when you force yourself to wake up with brute force and you are not getting the amount of sleep that your nervous system needs. will start to accelerate and in some ways it's a threat detection system because humans are the only species that deliberately deprive themselves of sleep for no good reason and when we see other species doing this, it's usually under very high threat conditions. by predators or starvation conditions and at that point the brain and body activate the sympathetic nervous system hyperdrive to try to help you stay awake because it is telling your brain that by not getting enough sleep you must be a threat. because the only time during evolution that I haven't gotten enough sleep is when I've been under attack, so it's no surprise that I tune in and feel quite alert.

The second problem, however, is that we say we feel more. alert we say we are operating and performing better, but your subjective sense of how well you are doing when you haven't had enough sleep is a miserable predictor of how well you are objectively doing with insufficient sleep, so this is kind of a so you know machismo you know I'm fine but in

truth

you know it's a bit like a drunk driver it's a bar they've had five or six drinks they pick up the car keys and they say look I think I'm fine to drive home and your answer is: I know subjectively you think you're fine, objectively you're incapacitated, don't worry, let me get the car keys, I'll call you a taxi, everything will be fine, same thing.

It's true with sleep, we don't know what sleep deprivation is when we're sleep deprived in terms of impaired performance, yeah, that's the line I was thinking of when I said it's the sympathetic response that makes you feel like you were awake uh when actually reaction time suffers creativity, productivity, all of that, uh, my last question before we end here is about sleep supplements, sleep treatments, medications, for me, just to give you my bias, I'm against it. of supplements unless there is an absolutely proven necessity to do so, um and yet there is a market for a cure-all miracle product for everything that we try and fight against on this sleep channel today, my Patients will turn to CBD.

Melatonin has cases where it works quite well. for jet lag sleep cycle issues, but in general, what do you think about some of these over-the-counter medications, whether it's chamomile teas, whether it's melatonins, whether it's the CBD supplement, are all of those? Yeah, you know, I think if there was this incredible compound or set of complementary compounds that was the Holy Grail of good sleep, that was the Shangri-La of all sleep, you know, concoctions, then, believe me, you know that the pharmaceutical companies They would have discovered it 20 or 30 years ago and now it would be a pharmaceutical product that we are making billions and there is no such thing, so if you know if you are seeing the promise of a better night's sleep by taking this supplement, you will probably disappointments, the evidence is very contradictory for almost everything you describe, we know that melatonin, you are absolutely right, can be effective when traveling between different time zones, but once it is stable in a new time zone, melatonin does not is the solution to most people's sleep problems, in fact, there is a meta-analysis which is a technique where we take all the individual studies and put them together and summarize them all and what they found is that melatonin .

I think if I remember my numbers correctly it just increased the total amount of sleep by um well. it only increased the speed with which you fall asleep by about 3.9 minutes, which relative to the placebo, you know, and then it only increased the efficiency of your sleep by 2.2 percent, which again is not a lot now that some people have said and I understand it, but if you feel like though it's working for you, the placebo effect is one of the most reliable effects in all of pharmacology, other than probably an injection of adrenaline into the heart, so You know there's no harm, no foul, the only thing I would say with melatonin is because it's not regulated.

I don't know what you're getting and there's a study that looked at a lot of different brands and what they found was that relative to what the label said, actually what was inside each tablet ranged from 80 percent less than what It said it's 460 percent more than what it said, so you don't know what you're getting. We also know a recent report from my dear friend, a wonderful pediatric sleep specialist, uh Craig Canapari, if anyone is a young parent. and if you need sleep tips, go to craig canoparia yale. He's a genius and he was just alerting people to a recent report showing that I think there was a 500 percent increase in reported overdoses of children with melatonin because you can go down to you know the grocery aisle, yeah, the doses , that's the thing and that's a great point, in fact, Mike, when it comes to melatonin and many of these other supplements, you are taking what we would normally describe as a suprophysiological dose, a dose that is much higher than anything that your body would create, see or produce and one of the concerns when you have super physiological doses and your testosterone supplementation is an example here that once you start giving the body an outsourced version, you have a feedback loop and you can stop or al less decrease your own production, so when taking too much melatonin (and most people do, maybe taking five or ten milligrams), the optimal dose seems to be between 0.8 and 3 milligrams, much less than the Most people are taking it, so keep that in mind, you have to be very judicious, but you also have to know that it doesn't seem to be that effective.

You know, things like magnesium don't seem to be very effective if you look at the literature, most magnesium. compounds that you buy out there and they don't even cross your brain, they don't cross something called the blood-brain barrier, magnesiumthree and eight um or mag-t, as you know, that may be the only exception and there is no good data on sleep. about that yet, um things like valerian root, chamomile tea is debatable, not really, uh, there is some evidence that I think is interesting in two areas, one is glycine and there have been some good studies that show from very Good laboratories provide some degree of consistent benefit from glycine anywhere.

I think anywhere from about one gram to about three grams, but again, in the wild west, you don't know what you're getting in the market and it's not a panacea for insomnia or difficulty sleeping, and then the other one is sour cherry juice. and Kiwis and I were looking at this evidence thinking this is nonsense, absolute nonsense, but again, the people who are doing the study are very respectable and the evidence was there in some animal cities and also in some human cities now that there are very few studies for either of We recommend people do that, but suppose it could be possible that both of these things are packed with something we call antioxidants and in the last four years there has been a revelation in the sleep field that antioxidants play An important paper.

A huge and powerful role in regulating our sleep and even protecting us from the ravages of insufficient sleep, so I think it's an interesting space. The last thing I would highlight is THC and CBD, and I also get asked this question frequently and I am sure. you do it too, tetrahydrocannabinol is the psychoactive component of cannabis, that is the part that gets you high and that can help people fall asleep faster or lose consciousness more quickly, but it is not a friend of sleep, first you you become tolerant and you become quite tolerant. quickly and you start having to take more to get the same sleep benefit, worse when you stop, you get intense sleep rebound. uh, in an insomnia syndrome, in fact, it is part of the cannabis withdrawal syndrome in the diagnostic manuals because it is very reliable.

The other thing about THC is that it can decrease or even block the amount of REM sleep you get, and we've talked about how that's critical. In fact, a lot of cannabis users, heavy cannabis users, will tell me, "You know, I just quit." dreaming and no, I don't really remember my dreams anymore because you're not getting much of that dream and then when they stop saying, I'm having these amazing vivid dreams, it's so surreal it's because your brain is trying to get some of that REM sleep back. of which he has been deprived for so long.

CBD doesn't have enough evidence, but it's interesting and I'm very careful about what I see here because you know when you have people like me and people say, "Okay, him." He seems to know a little about sleep, so if he said something then it must be that you know it well or scientifically, we don't have enough evidence about CBD to make recommendations for sleep. There is some evidence in animal studies in rats and some evidence in humans that at higher doses and I think those doses may have been higher than 25 milligrams. um maybe more may induce more sleep uh but one of the dangers is that at lower doses it actually seemed to promote awakening so it has this bimodal distribution and again you don't know what you're getting are you receiving CBD? very little and it's going to make you even worse because you're going to be more awake or it's going to be enough that you know it helps you sleep because I say it in quotes because we don't know if it helps um I think there are companies and you've known this for a long time. time.

I realized how bad of a scientist I am. Again I would go very purist about it and say these are snake oil companies, you know, selling things. stay away from them because there is no good science, well there will probably only be good scientists, sorry good science, if the scientists themselves stop having that exclusionary mentality and start working with some of these serious companies and help them make the studies and let's figure it out together, so I started working with a company that really focuses on very good medical practices with CBD and we'll see where it goes, let's think about a model where in 10 or five years we have evidence. that CBT is beneficial for sleep, how could I do it mechanically?

I think the evidence so far is for at least two interesting paths. One of the findings in animal studies was that when you give CBD to those animals, it can sometimes lower their body temperature. It can make them more hypothermic and, as we discussed, you need to lower your body temperature to sleep and sleep well, so maybe that's one way. The second is that CBD, and there is good science here, appears to be what we call an anxiolytic. a fancy word that just means it decreases your anxiety and you can see that in these emotional brain centers and in these anxiety centers good brain imaging studies have shown that this is how you and I talk about the fact that when you have this state of anxiety For the brain and the body, it will be very difficult for you to sleep, so if you have something that helps decrease anxiety, then in some way you will be taking the brake pedal off so that natural sleep occurs, instead to be a source of sleep. agent itself, it's really just removing one of the obstacles to your ability to generate the sleep you need, but again, we have no idea right now what's going on with CBD, there's a lot more work to do, yeah, that's the future rather than what patients want to take right now, so I think that's the importance, yeah, exactly, um, yeah, the quick, short follow-up that there is for my patients who are looking for prescription medications for help them sleep.

I really try to avoid that. highest degree um I don't want them to develop a tolerance or dependence um I want to find healthier ways to get them to sleep well uh in some cases it is necessary to do so um in cases where you use those medications You will find that it affects any of the natural ways that we experience the dream. Does the cycle length change? Does sleep rest change? Is it the same quality of sleep? of the sleeping medications that are being used, but the typical ones and I won't name any names that people know.

You are absolutely right again. Here is the situation where I am not a doctor, but I have spoken. For many doctors and medicine, it is very clear that there may be a time and place in which these medications are a lifesaver for people when they are in a very bad state of sleep, but we also know that medicine does not advocate for their long-term sleep. term. use and what you know is weeks, you know, if you look at some of the recommendations, not months and certainly not years, and if you look at the average duration of the sleeping pill, the user is in years, then something is wrong there um, I want to hammer.

This point is so strong for that very reason because many patients will find a doctor who is willing to do this for the rest of their life and I want them to know if they can get the same good quality sleep without BET as they do with the medication versus without it and sleep well. and obviously we can talk about the medical aspects of the negative effects of taking those medications, yes, so I think it's a great question, we certainly know that you can develop tolerance to them, etc. Sometimes you need more medication to get the same effect and when you stop using it you usually get a pretty unpleasant insomnia rebound effect where not only do you sleep poorly again and it can sometimes be even worse afterwards. longer duration, one of the findings in looking at some of these sleep medications is that if we go back to those deep electrical brain waves that I was describing, I can observe the electrical signature of your sleep using electrodes on your head and if you give people those typical sleep medications, sometimes, depending on the medication, you can get kind of a dent in the amount of deep sleep that they get in terms of the electrical brain wave patterns, so to your point, is it exactly the same type of sleep, from that data it can be argued that from what we call an electrophysiological perspective, from the electrical quality of your sleep, it is not the same as natural sleep, it seems to have differences, what are the consequences of those who We probably don't have enough?

There's no evidence yet to understand that and then there are also some side effects that you know of, of course, that you know very well. People have morning grogginess, they can have hangover effects, they can have cognitive problems during the day, and they don't believe. particularly well or they can't think clearly, so these are things to keep in mind and your doctor, you know, if he's as good a doctor as you, will help people understand those risk versus reward relationships and then you also know that there are other options, just like we talked about cognitive behavioral therapy that can help, and often cognitive behavioral therapy for insomnia is given along with some of these sleep medications to begin with, just to really help you. to know how to do it.

A big safety net under that patient captures them to start reassuring them because there's nothing worse and I've been through this with my insomnia, suddenly when you lose all confidence in being able to sleep, it's miserable night after night. you walk into the bedroom, you look at the bed and the bedroom is just your enemy, you just don't want to be, you know what's coming and suddenly, in that moment, your dream controls you, but with cognitive behavioral therapy for insomnia and these different approaches you can turn the tables you now control your sleep you regain your confidence and the ability you once had that you can start sleeping better there is someone who feels more like the former and not the latter there is hope for you talk to your doctor you can get better , yes, that cognitive behavioral principle is very interesting to my patients, especially those who believe that, whether due to their mental condition of anxiety, depression or insomnia, there is a chemical imbalance, we can address chemical imbalances with CBT as we have seen, as well is.

The therapy impacts the neurotransmitter chemicals in our brains and I'm sure it does, I can't speak exactly to the research, but I would expect you to see the same thing in your sleep waves from an EEG pattern in a sleep study, you absolutely can see. In so many different sleep metrics that are so well documented now, one of the benefits of cognitive behavioral therapy, as opposed to pharmacology, is that once you start working with your therapist and the classic approach is to maybe see someone you know for an hour and maybe you have six seven sessions of that once you're up and running rather than in terms of you know you hit the cruise control and you're on the freeway, at that point you know you can do very well.

Armed with all this knowledge and when you stop working with your therapist, those sleep benefits continue now, some have been documented five years later, whereas if you stop using sleeping pills you immediately go back to sleeping poorly, so I think those are some of the other advantages, yeah, that's amazing. There's so much overlap between mental health and sleep, so I'm very passionate about the topic, and obviously, Professor Walker, thank you very much for coming to talk about it. Thank you so much. We hope everyone reads his book. We have it listed below. I really enjoyed reading it, you have taught me a lot, so I want to thank you for your time, a privilege and a pleasure, thank you very much for having me and thank you for what you do, Mike, remember that making a podcast explode is not an easy task. so I need your help.

I need you to leave five star reviews and when you leave your review don't forget to add a medical question to the body of that review because I answer them at the end of every podcast, in fact, let's go to some right now we have Liz Walto asks a question is a resting heart rate of 110 beats per minute too high Liz we have to be very careful here because I don't want to say what is normal for you because I don't know your age I don't know what medical conditions you may have but generally speaking you want your heart rate to be minute be 60 to 100.

That said, I have a patient who is slightly above 100 and we still consider it normal for them. Yes I have. a patient who is around 50 years old, that is normal for them, yes, but remember that there is also a big difference with ages because the heart rate in younger people is higher and that could be the total norm for them, for That's important to get more information. When answering questions like this, Mitch knows 2525. I am currently in college pursuing a degree in Medical Laboratory Sciences at the University of Washington and plan to go to medical school, continue through medical school, and major in hematology.

I also do undergraduate research on the side and have started training in martial arts after stopping for a few years. I can understand, do you have any advice on how to cope with a busy schedule and avoid severe burnout, which has been an ever-looming threat for me and my colleagues? I think a lot about It's about balance and selectionof what takes up your time. If you are passionate about martial arts and the work you are doing with your education, don't eliminate those things from your life, but if you have certain things that What you are doing is lower on your priority list, you will definitely have to take some difficult decisions here, for example, I used to watch the NFL or basketball much more often than after I started boxing on social media and all this. things I even used to do in fantasy football, so things I once enjoyed doing started to take a backseat in my life because of the priorities I set for myself, so make sure you constantly reevaluate what is valuable to you .

It's not and constantly restructure it because sometimes those priorities can change and that's totally okay, but as long as you're insightful and in control, that's about as far as you can go when you're fighting burnout, at least avoiding the battle of burnout. . lady blushes medical question why do I sneeze when I'm really hungry usually several times in a row instead of my stomach growling interesting um I have no idea to be honest um most people their stomachs don't even growl when they're hungry that's More well, a kind of pseudoscience that we have created because it happened and people have propagated that myth.

However, it can happen because some hormones are released when you are hungry. There may be some type of histamine-related response related to when you are hungry. I'm hungry but nothing comes to mind sorry blush Sims one two three how bad diet soda is actually how bad I don't like to ever say something is good or bad, because that's not really a picture. full of what these things are: I'll tell you why I try to avoid diet soda as much as I can in everyday life, but if I had to choose between diet soda and regular soda, diet soda is probably a better choice if you're trying Control your sugars because diet sodas generally have no sugar and a regular soda has a ton of sugar.

I think I just saw that a can of cola has like 12 teaspoons of sugar, which is an absurd amount of sugar, so I prefer diet soda in this case. case because I am aware of the amount of sugars present and I don't want to bombard my body with sugar, but that might be different for other people with diet soda, the problem that arises is that you start using artificial sugar as a sweetener. there and that can cause some problems with the bacteria that live naturally in your gut. You can make some changes to where the bacteria that are in your gut can get calories from that sugar, uh, artificial sugar and multiply, which means you might start to develop cravings for more sugary foods, your taste buds will change because remember that many of these artificial sweeteners are sometimes even sweeter than normal sugar and that changes your psychology.

Do we have research that this is actually bad for you? Actually, it's not all my business. just opt ​​for water, sparkling water if you need a little twist and if you have a soft drink from time to time I will not be the doctor who attacks you for it because there are many risks in life and we must be very thorough and careful in handling of these risks and if you drink a soda once a month that is not the risk I will probably focus on for you as a patient. Well, we answered some questions. Keep asking me those questions because I want more.

Leave five star reviews as always, stay happy and healthy.