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Sleep is the Secret to Weight Loss -- Dr. Craig Primack MD, Scottsdale Weight Loss

Everyone knows about Diet and Exercise, Sleep may be even more important if you want to lose weight. Find out why in this video.

Doctor. Primack: Thank you. Thanks for coming. Tonight I’m going to talk about the relationship between weight and sleep. I’m going to tell a little story to start us off tonight. I’ve been doing this now for 13 years full-time. Someone in the first about two years, this guy’s still very vivid to me, the conversations we had about his weight and his sleep.

Doctor. Primack: We can take the three big things that go into weight loss. Diet, we all come in here, “Okay, diet,” there’s exercise, and there’s sleep. He was losing weight, unfortunately like guys often do, it’s fast. He got to a point where he was just about to go into maintenance, and then we picked up on this sleep thing. To give you a little story, he worked for a company that was based in Europe, and he was a manager, so he had weird conference calls, 2:00 in the morning, 5:00 in the morning. There were nights where he only slept just a few hours.

Doctor. Primack: We noticed that if he was on his diet, and he was exercising but not sleeping, his weight actually maintained. Then there’d be times where two or three weeks he didn’t have conference calls, so he was back to sleep, he was always an exerciser, that was his thing. His diet could soften up a little bit, and what did he do? He maintained. He had two of the three big things.

Doctor. Primack: If he had three of the three, he was losing. Two of the three, and we found out about any two of the three, he maintained. If he only had one of them, so his diet went off a little bit, and now he isn’t sleeping, because he has conference calls, he’s slowly gaining. Then if he had none of the three, you’re fast gaining. Now, the fast gaining I picked up now, since then. But we really looked very closely at all three of those variables in him.

Doctor. Primack: I said, “There’s got to be something with sleep.” This was back, I don’t know, 2006, ’07 or ’08, somewhere in that range, there wasn’t a lot published about sleep and weight. We didn’t know a lot about the hormones and everything else. So I said, “There’s got to be something more there.” So I started being aware. Every time a saw a medical journal published, something to do with sleep and weight, sleep and health, here I am reading at least the summary.

Doctor. Primack: I get an email every day, of the top things in the news. I can tell you at least once every three weeks, sometimes every two weeks, there’s something about sleep and health. This has been for the last years, and I’ve started keeping all these things. Now we know, and if anyone their first time in wasn’t sleeping seven hours, I probably told you three statistics.

Doctor. Primack: Number one, very simply, if you’re sleeping less than seven hours, you’re more likely to be overweight. Sleeping more than seven hours, you’re less likely to be overweight. They did a study, it was done initially on women. But it was if they were sleeping five hours, they went around all the five-hour sleepers, and they said, “How many of them are overweight?” It was 80%. 80%! Oh, my gosh! What’s going on? So we’re going to learn about that.

Doctor. Primack: Then the last one, and we will talk about this study a little bit is they took people who were sleeping eight and a half hours and compared their metabolism to people sleeping five and a half hours, which is all too common in our world. Not just in a clinic like this, but in our world. Their metabolism fell 400 calories a day. You try to do the things you want to do, you go on a diet, you start exercising, and you don’t see the results you’re looking for? Number one I see in the clinic is sleep, and that’s what I talk about sleep incessantly.

Doctor. Primack: That is what got me interested in this sleep thing. I had been asking for about two years at my society, “I want to give a talk on sleep.” Finally, I touched the right person at the right time, and they said, “Do it.” In January or December of this year, they said, “We’re going to do it this next week,” and so I started putting this talk together. That’s why I’ve been so interested in sleep, as a topic on this.

Doctor. Primack: So tonight we’re talking about the “why” to sleep? Why do we need to sleep? It is not just weight, it is health. I started talking about this with some people in the office, and I was going to title this subsection, “Why do we need to waste eight hours a day sleeping?” I said that to the right person, they go, “That’s not waste. I like sleeping.” I didn’t say it, that wasn’t the right topic to do. I don’t think it’s waste, so I didn’t even want to put that at all into this thing. So it’s Why Should We Sleep?

Doctor. Primack: The second is, there are some major sleep disorders that we see, that make it harder for people to sleep. Sleep apnea being number one, and restless legs syndrome being number two, and they’re both treatable conditions. Number three, you can’t leave one of my talks without learning something you can do tomorrow. So we talk a little bit about sleep, and how to sleep better.

Doctor. Primack: I’m not going to go into a lot, a lot of detail, but I’m going to hit a lot of topics. Some of them about medicines, some about things you can do at bedtime regarding lights, and sounds, and a lot of things I talk about daily. Some about medicines, and so forth. That’s what we’re going to accomplish.

Doctor. Primack: What’s happening in the US? American adults who are sleeping eight hours, back in 1998, so this is now 20 years ago, 35%, so one out of every three. Not great. In 2005 only one out of four, 26%. We’re 2019, do you think it’s less? Absolutely. Here’s another statistic. That was just how many are getting eight hours of sleep. So average duration back in 1960 …

Doctor. Primack: 1960, remember I grew up in Chicago. We had how many television channels? Two, five, seven, nine, 11, 32, 44, 60-something. We had eight TV channels. How many TV channels do you have now? There’s always something on, you can stream it at any time day or night. We have those computers in our pockets. So in 1960 when they were sleeping eight hours we didn’t have any of that stuff.

Doctor. Primack: 1995, seven hours we still didn’t. What year did the iPhone come out?

Audience: 2008.

Doctor. Primack: 2007, yeah. Netflix streaming, what year did it come out? 2007, absolutely; now it’s everywhere. Unlimited data, unlimited everything else, people are tied to their screens. Screen time and time away from sleep is costing us health. Japan, it was better than us, or maybe. Because we took 8-9, they were 8:13 Then 7:32 in 1995. Again, still, they have the same technology we have, so it’s getting worse.

Doctor. Primack: What’s happening? If we take insufficient sleep as the base, there’s something called homeostatic feeding behavior. The up-regulation of appetite-stimulating hormones, the things I talk about all the time that’s going on in the brain. We get more hungry when we’re not sleeping. There’s, hunger goes up.

Doctor. Primack: Non-homeostatic, not regulation, so the rewarding value of food. Foods that have fat, and sugar and salt look better and taste better to us when we’re sleep deprived, and we want them more than a salad all the time, not just sometimes.

Doctor. Primack: Energy intake goes up, leading to what factor? Physical activity most likely, this is question mark, but most likely when you’re tired you’re going to give up the gym more often than not. Therefore, increasing fatigue, less energy expenditure leading again to more fat. All roads leading to really these two things.

Doctor. Primack: Why don’t we sleep? This was an interesting study. There was a questionnaire’s given to people, and it asked them two questions. How much psychological distress do you have? That was really defined as three things: how much anxiety, how depression, and how much just overall stress over your ordinary you have? People graded it, themselves. It’s a lot, so: excellent, very good, and so forth down the road.

Doctor. Primack: Then you’re self-perceived health status. Ever go in and talk to your doctor, they’d have you list all your medical things? Again, do you have excellent health, very good health and so forth? What they looked at when they saw that, is if you put down you have excellent or very good health, and you have low distress, you actually slept.

Doctor. Primack: Only 5% of all the people slept less than six hours. Another 20% slept six to seven hours. If you said you had low psychological distress and pretty good health, 75% of those people are actually sleeping seven or more hours.

Doctor. Primack: There was one, call it an exception. There’s always an exception to the rule. People who exercise a lot. They said if you had vigorous leisure activity that was seven hours or more per week, or three or more strength training sessions per week, was this both associated with sleep less than six hours.

Doctor. Primack: I think of that as the Ironman triathletes. We all know Ironman triathletes in our vicinity. They’re doing roughly four hours of exercise, most days training. You have to ask is that healthy? I personal biases. It may not be healthy. We haven’t truly proven it, but it’s a lot of exercise and they’re losing out on sleep.

Doctor. Primack: This is an interesting one. Someone was trying to come up, what is the function of sleep? We talked about it. It takes short term memory and translates it into long term memories. It’s almost like refiling when we used to have computers that defragmented, you’d have to set it in three hours later you’d come back and it would be all easier to use. They would be faster. We don’t do that anymore. But, when we do that, that’s kind of what our brains are doing at night.

Doctor. Primack: So this doctor, I don’t know if he’s a doctor. But, Daniel Gartenberg is a researcher at Pennsylvania State. He said we need eight and a half hours a night to do this process, that he described this synaptic homeostasis. All the synapses, all the brain connections, they rewire just a little bit every single night.

Doctor. Primack: We have a lot of information coming into our brains. We’re bombarded with information from the modern world. In computer terms, he said we have 34 gigabytes of information coming into our brains every day, from Internet, from work, from everything. It takes time every night, to file that away.

Doctor. Primack: If we say, “Yeah, my memory’s not good for that thing,” the less sleep we get, the more true that’s going to be. We have to be able to sleep, to take short term memories and make them long term memories. So, our functions get the sleep that is necessary.

Doctor. Primack: Let’s talk about health, not just weight. But number one on the list here is weight. Insufficient sleep is associated with weight. Type 2 diabetes, heart disease, hypertension, abnormal immune function. Which may be, if you take it a step further, cancer-related. Because our immune system is changed, with cancers that grow out of control. Then, unfortunately, premature death. The end-all of not being healthy.

Doctor. Primack: If we get specific about endocrine manifestations, decreased glucose tolerance leading to diabetes. Decreased insulin sensitivity, again towards diabetes and such. Increased evening cortisol. Cortisol is our stress hormone, so more stressful on our body. Increased ghrelin and leptin. I talk about leptin and ghrelin all the time. I talk about it again in a couple of slides, but those are hunger hormones.

Doctor. Primack: I’ll say it a few times. We want leptin to be high, it tells our body we’re full. We want ghrelin to be low, it tells us we’re not hungry. Right before a meal, the ghrelin comes from the stomach. It comes up, we eat our meal and it goes back down. Leptin comes from our fat, so it kind of does, as we lose a significant amount of weight, it does come down also. Therefore, leading to increased hunger and appetite. So we can measure many of these hormones in the body.

Doctor. Primack: Sleep facts. Let’s talk about kids. The next generation they’ve said is now going to live shorter than the current generations. Because of weight, and diabetes and diseases like that. Kids who sleep less than 10 hours, 10 hours are 89% greater risk than their peers to have obesity.

Doctor. Primack: I started to try to do the math of that. My kids go to bed at nine o’clock. What time do I have to wake up … and, no. Kids are not sleeping enough. School starts, probably too early and we’d known that for years. It just isn’t changing anytime soon.

Doctor. Primack: Adults sleeping less than five hours, I won’t ask for a show of hands. But I’m sure there are people in this room that often sleep, if not all the time, sleep less than five hours. 55% more likely to have obesity than those sleeping greater than five hours. Just that. It’s not what you’re eating. I mean that comes into it. There’s not more exercising, it’s just sleep related.

Doctor. Primack: A reduction of one hour of sleep is associated with a 0.35 increase in BMI points. And less sleep. Morning types have lower BMI than evening types. Luckily, I am probably the number one most morning type of person in this room. I have never in my life slept past 9:00 AM, ever.

Doctor. Primack: I’m up on my own between 5:00 and 6:00. It’s just me, I didn’t do anything that to do it. But, so many people are evening types. Most of the time that’s probably somewhat genetically determined, or it’s habitually determined; regarding work in all those other things.

Doctor. Primack: Late sleepers eat 248 more calories per day on average, mostly from dinner and after. That has part to do with hormones and the hormones that change throughout the day. Also, to do with our circadian rhythms and when our bodies should be awake versus asleep. Beyond daylight, beyond when we typically go to sleep, food helps reset circadian rhythm. If we’re feeding ourselves at different times, it sets the whole cycle off.

Doctor. Primack: This is a reference. I’m going to talk a lot about it when I talk to the doctors and everyone next week. But, in the New England Journal of Medicine in 2011 is this article here. It’s called, The Long-Term Persistence of Hormonal Adaptations to Weight Loss. This is, in my world, it’s called the Sumithran article; he’s the main author.

Doctor. Primack: It’s what, for me, changed weight from a personal problem to a medical condition. This is the one that says with leptin and ghrelin, we want leptin to be high and ghrelin to be low. When you lose weight, they begin to do this. The more weight you lose, the leptin comes down because we lost that, and the ghrelin comes up all the time more. Starts at a higher level goes to potentially a higher level.

Doctor. Primack: That’s where you said, “In the beginning of my program, I was able to not eat certain foods even when they were wrong. But a little bit later, that looked a little good, and that looked a little good.” It isn’t a willpower thing. It’s the hormones inside of us saying, “Eat.”

Doctor. Primack: What happens is, that either changes our hormones so that we’ve slowly regained weight, and they tend to go back to normal. Or, we’ve studied them for a year, and they don’t go back to normal, they don’t reset. There’s always that little voice saying, “Eat.” That’s why we have to do techniques, that counteract those hormones.

Doctor. Primack: Including, as we do here, higher protein diets, fewer carbohydrate diets, medications, sleep. Exercising makes. Some combination of that is what works for most of us. Using that is why these things happen, let’s talk about leptin. Because leptin has now been studied a lot regarding sleep.

Doctor. Primack: Two nights of four hours of sleep. We use seven or eight hours as our baseline. In this study, it was eight hours instead of 10 hours. 18% decrease in circulating leptin. Leptin again is telling us our body is working fine. Metabolism stays high, you stay satiated longer, full longer. A 28% increase in ghrelin, more hungry. Just from two nights, decreased to four hours.

Doctor. Primack: Increased hunger and appetite is what we get. Leptin also decreases with fasting. This whole big push with intermittent fasting, I still think the jury is out. Because what’s happening is, our metabolisms falling, our muscle mass may be coming down. Our bodies doing things that slow our metabolism, with less leptin.

Doctor. Primack: And inflammation, stress causing inflammation. Lack of sleep causing inflammation, and other medical conditions that are not related to weight or anything causing inflammation can all be related to this. Leptin should be extra or goes up during sleep. Since the time we haven’t eaten, it’s higher during sleep.

Doctor. Primack: It’s decreased with sleep restriction, 19% versus extending sleep, or sleeping longer than normal. It’s inhibited via the sympathetic nervous system. That’s the nervous system, that’s the fight or flight. When we have stress, this is decreased.

Doctor. Primack: It mirrors, so the opposite of cortisol. Cortisol high, leptin low. That’s, stress goes high and what? Fullness goes down. We all know that. When I’m stressed out, I eat more food. It makes sense, but we’ve studied it in blood, in humans. There’s a lot of details here because I think it’s important; this is the point I want to make.

Doctor. Primack: Six days of four hours of sleep, decrease leptin levels by 26%. Two days versus extending it, so going an extra four hours. Leptin decreased by 18%, ghrelin decreased by 28%. That again, hunger increases proportionately about 24%. Appetite went up 23%.

Doctor. Primack: This goes back to again, I think, cutting calories too much or intermittent fasting. Three days of 70% calorie intake, so they out 900 calories a day out, decreased leptin by 22% in this study. Why is leptin go down when we’re fasting and such?

Doctor. Primack: It’s probably because the body’s going to say, “I’m going to need more calories. I don’t know where they’re going to come from. If I slow your metabolism down, the ones I have are going to last longer.” That’s kind of what we’d been saying here.

Doctor. Primack: Graphs. Let me Orient you. First, four hours of sleep versus 12 hours of sleep. So one is too short, one potentially longer, but maybe even too long, which we’ll get to. Leptin, the hormone we’re talking about, if you just look at numbers, it’s lower versus higher. That’s the first thing to take away from it.

Doctor. Primack: The time that they were asleep, is this little black line in both of them. You can see the short sleep, long sleep. This is the peak leptin, it’s not even happening during sleep, as when it should happen. Here, it’s happening a little differently but it is happening actually during sleep, which is good.

Doctor. Primack: Cortisol, our stress hormone, during sleep right here, the curve leading up and after it is different in these two. This is the better stage, at being the worst state when you look at Cortisol.

Doctor. Primack: So what are the benefits of sleeping six to eight hours? I say, okay, we’re going to start establishing that as the window. Seven hours on the low side, nine hours on the high side. But this looked at, better mood, better ability to focus. It’s that memory thing working better again.

Doctor. Primack: Decrease in daytime sleepiness, people falling asleep at the wheel. Night shift workers very, happened to a lot of them, falling asleep at the wheel. More willingness to exercise, helps burn more calories. A decrease, therefore, in caffeine intake. That makes sense. Less cravings, as I talked about a few minutes ago, for sweet and salty foods, especially in the evening. The time we probably shouldn’t be having more food.

Doctor. Primack: If you turn that pyramid upside down: big Meal for breakfast, medium meal for lunch, and a smaller meal for dinner. Like the American upside downed this. Or we’re really, really upside down on, our biggest meals come from 7:00 PM to 11:00 PM, in many people.

Doctor. Primack: Lower risk of cardiovascular events, and death by sleeping. I wanted to emphasize it. This is health. We come here, and we do this weight loss for health. One of the major things, before we even start dieting exercise is sleep.

Doctor. Primack: Does sleep help fat loss? Yes. Similar weight loss. Interestingly, so two people eating the same foods, doing the same exercise, one sleeping eight and a half hours, the other sleeping five and a half hours. Only 25% of the weight loss when you were sleeping shorter was fat. So your fat loss went down, your muscle loss went up.

Doctor. Primack: Fat went down by 55% less fat loss, than the person sleeping eight and a half hours. Free Fat Mass loss, which is for all intents and purposes, muscle, when we talk about it here. It increased by 60%. 60% increase in muscle loss, even though we were losing weight. So the scale looked the same, but inside of us we weren’t as healthy.

Doctor. Primack: 5.5 hours of shorter sleep also showed, as we talked about ghrelin, lower resting metabolic rate; our metabolism slowed down. Here’s where I talk about, 920 calories versus 520 calories, that’s 400 calories less. If you want to do something else with this is 400 calories, if you want to walk 400 calories worth, how far are you going to walk?

Doctor. Primack: Did we just play this game?

Audience: Yes.

Doctor. Primack: So one mile is a hundred calories. The average person takes 20 minutes to walk it. This is an hour and 20 minutes of walking. We’re asleep. You know, I actually like exercise, but if the choice is I’m going to go out and do an hour and 20 minutes, or I’m going to sleep a little bit more, I’ll sleep a little bit more first. Then we’ll feel better, and we’ll want to do the exercise more.

Doctor. Primack: This was an interesting graph, and I’m also going to spend a minute to take you through. Respiratory quotient is numbers that you could do through a breathing test and we’ll tell you how much fat you’re burning versus carbohydrate. What you want if you’re burning all fat, you’re at 0.7 so that is at the bottom here. If you’re burning all carbohydrate, you’re up at 1.0. The higher you go, the less fat you’re burning.

Doctor. Primack: Here we have people sleeping eight and a half hours, are white, so they’re burning more fat. This is before the meal, an hour after, because of what the what’s in the meal, you’re going to burn a little more carbohydrate. Then as that gets used, then your body starts drawing on your own fat stores again, your fat burning goes up.

Doctor. Primack: Well look at this. Same thing, same person, just not sleeping, three hours less. This is all I’m talking about is three hours less. For every point down there, they are burning less fat. Make sense? We’re going to change from overall sleep to diabetes. Because diabetes is correlated as we’ll see, very strongly.

Doctor. Primack: The incidence of type 2 diabetes in the US, 760 people for every 100,000 in the US right now. A whole bunch upon that have prediabetes, before that. 68 cases of diabetes for every 100 increase, for every one hour of reduction less than seven hours. So that’s 9% extra people because they’re not getting sleep.

Doctor. Primack: Compare that to seven hours at the bottom here, an hour decrease increased type 2 diabetes by almost 10%, 9%. Now, our increase over normal. We’ll go back to, there is a window you want, to go below that it’s not healthy, and if you go over nine it’s not as healthy either. Sleep restriction gives insulin resistance in human adipose sites. Adipose sites are human fat cells. So the cell itself is showing insulin resistance.

Doctor. Primack: They are the key set of insulin action, energy metabolism, and then the fat cells are sending signals to the brain; they’re telling the body what to do. If they’re saying I’m insulin resistance, it’s, “Send more sugar my way, because I don’t have the sugar I need.”

Doctor. Primack: In Vivo, 30% decrease in cellular sensitivity after four nights less sleep. That’s all it takes. Four nights less sleep, and we’re seeing a difference. With sleep restriction … and this along to the next slide. REM sleep, our dreaming stage, was reduced by 56.8%. Wow.

Doctor. Primack: Let’s talk about melatonin. This is interesting … this is super early stuff, but lower melatonin secretion was independently associated with type 2 diabetes. So, less dreaming stage, less deep sleep, less melatonin naturally. In several studies, they looked at SNPS. SNPS are little tests you can do, that look at specific markers in the blood, and you can find errors in the genetics. So, there’s something wrong with these type D melatonin receptors.

Doctor. Primack: If you found these abnormalities, then the Melatonin wasn’t working exactly like other people’s. We had higher fasting sugar, diabetes or prediabetes. Higher hemoglobin A1C, what we do to measure diabetes over a three month period. An increased incidence of gestational. So even gestational, we’re going to say, those are even younger people, because they’re pregnancy age. And type 2 diabetes.

Doctor. Primack: Men who reported sleeping less than five hours, two times more likely to develop diabetes than sleeping over seven hours. So, two times more. That’s a lot.

Doctor. Primack: Now this last two pieces, I just thought were interesting. We haven’t done any human studies. So these are rats and mice. Rats and mice are not small humans. But they say if it works there, we should study these things in humans. Rats are awake at night and asleep during the day, and we’re the exact opposite. But, they eat for many, many different reasons, and we do.

Doctor. Primack: But anyway, giving them melatonin protected them from diabetes, who were diabetes prone. And from developing hyperlipidemia, hyperglycemia, and hyperleptinemia. The insulin resistant mice, have reversed our insulin resistance. I don’t know if it helped them to sleep better, or what? It’s mice, we can’t ask them the questions. But, I think this should lead to someone doing pilot studies on humans, and that. I wasn’t able to find anything on that, so I don’t know.

Doctor. Primack: This is a curve talking about, relative risk of type 2 diabetes. A 1 risk is your base standard risk, you’re the same. As you go up, 10% increase, 20, and 30, 40. 2 would be a double the risk. This dark line is the average population, with arrow bars on each side. And you can see here, about seven hours, seven and three-quarter hours, is the least amount of risk. We called this a U-curve. So if you go too far this side, if you’re at seven and a half of you sleep less, your risk of diabetes goes up.

Doctor. Primack: If you’re at seven and a half hours, you go up much more, you’re sleeping 10 hours a night, it’s as bad as potentially sleeping six hours a night. We don’t know exactly why that is, by the way. Sometimes people who have other health conditions that they sleep longer, or they have sleep apnea, they’re not getting quality sleep during that time and such, are in bed longer because they aren’t getting the sleep. Or, are other health conditions. We don’t know exactly.

Doctor. Primack: Let’s switch gears. We’re getting into the two diseases that I mentioned briefly. So the first one is obstructive sleep apnea. Every time I talk to someone about obstructive sleep apnea, and this is the picture that pops in their head. This is the picture that should pop in our head, right? Right? It’s not this one. It should be this one. It’s good to have a CPAP mask.

Doctor. Primack: What is sleep apnea? It’s a temporary stop or decrease in breathing during sleep. An apnea is actually stopping breathing, so complete stoppage of breathing. Hypopnea, so not complete, but a partial obstruction of oxygen flow. You’re desaturations, if you’re checking saturations, go down by at least 3%. It lasts about a minimum of 10 seconds when they’re measuring it. In a positive test, you’re having 15 or more per hour.

Doctor. Primack: They have a thing called AHI, Apnea Hypopnea Index. That’s to take your apneas and your hypopneas, add them together, and it gives you a number per hour. Once you hit 15, you have it. Unless you have a lot of other health concerns, and then we’re more sensitive, so even five an hour can be it.

Doctor. Primack: Predictive, loud snoring, the number one best thing people say, “Yes, loud snoring.” And I ask, does anyone here use [inaudible 00:29:22]? I ask that one every single time we talk about snoring. Gasping, just being overweight, as we’ll talk about the statistics regarding it. And then an increased neck circumference, more tissue in our neck. Then the higher we go, the more likely. It starts at about 15 and a half, probably increased risk. And 16, and 16 and a half, and 17, and 18, and 19, the higher the risk. But that’s where we start risk.

Doctor. Primack: Test is called a Nocturnal Polysomnography, so a sleep study. It can be done in a sleep lab or done at home. Sometimes we’ll try to do, and get it all done and call it in one night if we really think you have sleep apnea. The first part of the night you do the regular test. After about two hours, if they notice your number of apneas or hypopneas are at least 20, they’ll say, “Okay, you do have sleep apnea.” The second half of the night don’t actually work on finding the mask to you and seeing how much pressure in such that you need.

Doctor. Primack: The home tests, which unfortunately a lot of insurances are mandating as your first step, are not as accurate. They can more often rule it in, but they’re not good at ruling it out. It is easier to do a home test. Something on your hand and I think there’s one electrode. You sleep in your own bed and everything else.

Doctor. Primack: Where a sleep study, my son did have a sleep study when he was six , and I went with them to the lab. And yes, there’s a lot of things on him, and you’re sleeping in a room that looks like a hotel room. It is somewhat harder to sleep. But trust me, if you have sleep apnea, it is worth doing the test. Or, if you think you have sleep apnea, it’s worth doing the test.

Doctor. Primack: Home testing is not indicated with a few conditions, congestive heart failure, chronic lung disease, or other neurologic conditions with a lot of movements and such. If you’re sleeping on your back supine versus on your side laterally, sleeping on your back doubles your snoring. And your hypopnea index.

Doctor. Primack: For a while, we talked about getting a t-shirt and sewing tennis balls on the back. Every time you roll your back, it would press on your back, so you’d roll back to your side. I don’t know if those were even available, but we talked about that years and years ago.

Doctor. Primack: Other treatments besides continuous pressure mask, a mandibular advancement device, a job positioning device, and there’s a bunch of different ones. There’s certain dentist in town and certain specialists, who make those for you. Something called a UPPP. A UPPP is basically where they take out your palate and the little thing, remember the little thing’s called?

Audience: Uvula.

Doctor. Primack: Uvula, thank you. Did you ever see that Fireside, years ago? It’s like final exam, or it was like bonus question on your medicine school tests, and what was the little thing called in the back? Neurostimulation to the hypoglossal nerve, which helps tighten up the loose muscles. I have not actually seen that one used, but it is available.

Doctor. Primack: The STOP Bang Questionnaire. This is probably the best of the questions, to say when you screen someone, do I think they have sleep apnea? Is it worth going on for the next stage and getting a sleep study? So, S-T-O-P Bang are the eight questions. The first one is, do you snore loudly? Yes or no? Tired. Do you feel fatigued, tired or sleepy during the daytime? Trouble staying asleep.

Doctor. Primack: Observe apnea, has anyone heard that you gasp or wheeze a while you’re sleeping? High blood pressure, are you treated for high blood pressure? BMI, is your body mass index more than 35. That’s what we’ll call class two obesity. Are you older than 50? Is your neck greater than 15.75? Men know that because of shirt size. We have measuring, that we can measure other people. And Are you a male?

Doctor. Primack: If you have 0-2 you’re at low risk, 3-4 you’re at medium risk, and you are greater than 5, you have high risk. How many?

Male: Oh, I hit them all.

Doctor. Primack: Okay. The elbow sign. Have I told any of you guys about the elbow sign? So I was looking for a picture. What does the elbow sign? It’s not this. This is what I said was the elbow sign. But it’s actually being elbowed by the person you share your bed with.

Doctor. Primack: It’s like, “Wake up, wake up.” If you have sleep apnea, it’s seen the 97% of people who have sleep apnea. At some time or another. It may not be an every night occurrence, but at some point they’re like, “I wanted to make sure you were still breathing,” is what I hear all the time.

Doctor. Primack: In the US, so let’s talk about it. Is it popular? Absolutely. 24% to 25% of all men in the US have sleep apnea. 9% of women. If you have severe obesity, 93% of all men. What do you call that thing? Shooting fish in a barrel? 93.6% and says you have sleep apnea. 73%, so three out of every four women.

Doctor. Primack: What does sleep apnea make worse? What health conditions? Hypertension, I’ve underlined that two or three times. Every time I see someone who’s on three or four or five blood pressure medicines, the first thing I think about is sleep apnea, and hard to control. Congestive heart failure, atrial fibrillation, stressing the heart, diabetes and pulmonary hypertension. Just not breathing, loading the heart at night.

Doctor. Primack: This was, the odds of having a condition, and we’ll talk about these conditions, plus obstructive sleep apnea versus just having obstructive sleep apnea. So we’ll run this together. Atrial fibrillation, a four time odds. Depression, 2.6 time. Congestive heart failure, stroke, hypertension, coronary artery disease and diabetes. All of these things that run with not sleeping well.

Doctor. Primack: So if you gain 10% of your weight from wherever you are today, your apnea hypopnea index increases by 30%. And you get a six times increase in moderate and severe obstructive sleep apnea. If you have a 10% loss, 26% decrease. The numbers that you can hear, people getting like an AHI of 60 is one time every minute. An AHI of 90 is one, well, 45 seconds or so. But 120 would be every 30 seconds, they’re having an apnea. Those are possible results. Freaking out. Yes.

Doctor. Primack: Let’s tie it back to leptin. Let’s tie it back to these hormones. Leptin levels are elevated in sleep apnea. Plasma leptin was 50% higher in patients with sleep apnea, that match controls. But what we found there, in these people, especially, it’s independent of the amount of weight they have. Because, leptin is made by our fat cells. So what they’re saying is, there’s a resistance to the leptin that they have.

Doctor. Primack: With leptin, we want our metabolism to be good and fullness, but we’re resistant to that. But we may not be resistant to the sympathetic drive, what it’s doing to our body as far as stress is concerned. Two days of CPAP, just being on treatment for two days decreases ghrelin levels, decrease his hunger. We don’t see a change in leptin, adiponectin, which is another protective hormone or resistant. I want it to be 100% complete. You can’t paint a picture, of just goodness with everything.

Doctor. Primack: There was an increase in insulin and insulin resistance, but it was proportional to the BMI. So there was a small, and we’ll talk about how much, a small increased weight when people went on CPAP. But their health, I have to say that time and time again, their health overall improved. Ghrelin was inversely correlated with insulin resistance. So when the ghrelin went down, the insulin resistance went up, but didn’t change with the weight.

Doctor. Primack: Now, lets officially answering that question. Does CPAP increase weight? And the answer is, yes. It promotes a very small BMI and weight increase. Be a lot of changes. It was 0.5 kilos. That’s about a pound to a pound and a half on average in the study. Now it was interesting. We got this from 25 studies all lumped together, to make up only 3000 patients. Which, in the medical world is not a big study.

Doctor. Primack: None of these studies actually looked at what people were eating, nor what they were doing for exercise. You have to control for these things. One person maybe eating more, one person maybe in the last, it was across the board, not controlled for it. So yes, we can say that people are healthier, but you may not lose weight by treating your sleep apnea. One unit less BMI, gives 2.3 less on apnea hypopnea index. That’s how many times per hour less.

Doctor. Primack: Massive weight loss. If you lost 17.9 BMI points, you’ve lost 38.2 points on your apnea hypopnea index, but only 4% had resolution of their sleep apnea. I did have a gentleman that had, we studied, so he weighed about 270 pounds with sleep apnea. He lost 70 pounds, and went on to get restudied, he did resolve his sleep apnea. When his weight went back up, unfortunately, he did go back on CPAP and such.

Doctor. Primack: Most people I have who lose that amount of weight with sleep apnea, don’t want to have studies again. Nowadays, with newer and newer machines, self-titrate. So if you needed a lot of pressure in the beginning, the machines will bring the pressure down is you need less pressure, also. So there’s less and less reasons to potentially be restudied.

Doctor. Primack: CPAP treatment. So here, health benefits. Reduces daytime sleepiness, improves quality of life, lowers blood pressure, reduces visceral fat. So overall weight didn’t change, but again, visceral fat, the unhealthy fat, the one that wraps around the organs did go down. Improved glycemic control and insulin sensitivity. We did get healthier by going on CPAP.

Doctor. Primack: How was it connected to blood pressure? When you have sleep apnea, your blood pressure, it should go down while you’re sleeping. And sympathetic activity, the amount of muscle activation stress during the day, should go down during sleep and it did not. This was secondary to apnea, so stopping, breathing. Hypoxia, your oxygen levels falling during this apnea. Hypercapnia, which is you’re carbon dioxide levels going up.

Doctor. Primack: Then, breathing against a closed glottis. So, if you try to tighten your throat and breathe in, that happens during the apnea. Then, being awakened during the middle of the night. Blood pressure in this study maxed out during sleep 240 over 130. If anyone is in the office with a 240 over 130, you are directly being driven to the emergency room. This is a hypertensive emergency. It is happening to people while they sleep, all the time.

Doctor. Primack: Sympathetic activity increased 125%. This is versus being awake. This is why you should be sleeping and resting. O2 saturations when you were on CPAP went up by 20%, and it was never less than 90%. So, CPAP helps. Oxygen’s good. So, the good. Incidence of mortality, morbidity and health are reduced by using CPAP. The bad, weight may not change very much. But, you’ll feel better, you’ll sleep better, you’ll have more energy, and you’ll have all the benefits.

Doctor. Primack: This is a tracing from a sleep study. Sympathetic nervous activity. I think in this one, they actually did muscle. They put an electrode on, and saw how the muscles we’re moving. This is respiration. So this breathing normally, and then this is not breathing. Breathing normally, not breathing. And so each episode here is a separate sleep apnea. And what’d you see is, during breathing this was calm. During apnea, these muscle fibers are firing very fast, and blood pressure goes up at the end of your sleep apnea each time. Not Good.

Doctor. Primack: Let’s change gears. Restless legs syndrome. Restless legs syndrome, I’ve known about, even before I really knew about it. My grandfather, who’s now passed, had restless legs syndrome. At night, he’d talk about his legs kicking almost like a bicycle. And we’d be out, and there’s an itchy sensation … we’ll talk about all the details, an itchy sensation. We’d be out to dinner, and he’d say, “My legs are itching again,” and he’d have to walk around the restaurant a few times, he’d come and sit down.

Doctor. Primack: It does run in families, and there are other people in my family that have restless legs syndrome. Luckily, it didn’t hit me. So, I’ve been aware of this for a long time. It’s a neurologic movement disorder, with an irresistible urge to move your legs. It has this thing called, periodic leg movements of sleep. It happened in about 80% of, most of the people were diagnosed with it, have that one with it.

Doctor. Primack: These motions last a half a second to a second, and happen not continuously. They happen, and then there’s about five to a minute and a half, they don’t do any. Then, they move again and so forth. A lot of people I asked, “Do you kick the blanket off?” If you’re kicking the blanket off in the middle of the night, and you’re the only one sleeping in the bed, you’ll probably have this.

Doctor. Primack: Then you usually flex at the knee and the hip, and you dorsiflexion at the ankle. So it’s this kind of movement, and it’s almost like a bicycle movement while you’re in your bed. Disagreeable sensations. So people don’t like this. It’s not a good feeling. And it usually happens with less activity. So at nighttime, when you’re laying there, more likely when you’re sitting down, more than likely. It interferes with sleep.

Doctor. Primack: Two to 15% of the population. So, this is pretty common. It has probably a genetic origin, and does run in families, for sure. We don’t have a gene that we can test for it, but it definitely runs in families. Urge to move the legs, usually, but not always accompanied by uncomfortable and unpleasant sensations. It happens during periods of inactivity, such as lying or sitting. It is unpleasant and when you move, it often takes these sensations away. More often during the night, or times when you’re sitting.

Doctor. Primack: Positive response, is supportive things. There’s a positive response to the medical treatment. Periodic limb movements, the ones that we talked about, the moving. Then, a family history. You have to make sure it’s not something else, when we talk about restless legs syndrome. Iron deficiency runs very, very often with restless legs syndrome. There’s a measure of iron deficiency called ferritin, and if it’s less than 50, it’s suggestive with these things. Severe iron deficiency is with a sixfold increase, or six times increase in restless legs syndrome.

Doctor. Primack: If you have neurologic lesions of your spine, or peripherally, you have to make sure it’s not from that. That you’re not pregnant, because it’s seen a lot of times in pregnancy, and that again may go along with iron. Uremia, so end-stage renal disease. If you have end-stage renal disease, your dialysis, you’re uremic levels go up. Then certain medicines, SSRIs are on the list, lithium is on the list. Dopamine antagonists that we’ll talk about, and caffeine does make it worse. And tricyclic antidepressants.

Doctor. Primack: You have to make sure, it’s not just nighttime leg cramps. Nighttime leg cramps are painful. They’re muscle contractions that happen, often focal, often not unilateral, sudden onset. Akathisia is a side effect from certain medications, dopamine medicines, the ones that call the anti-psychotic medications, much more common.

Doctor. Primack: Peripheral neuropathy, that can happen with diabetes, or sometimes idiopathically. Or vascular disease, like having deep venous thrombosis or blood clots in the legs. You want to make sure it’s none of these things, before you can call it restless legs syndrome. When your doctor’s examining you, they want to do a good neurologic exam looking for these things. Especially, the spinal cord and peripheral nerves, a vascular exam to rule out any blood clots and things like that. Then, there’s blood tests. I’m going to talk about blood tests on a future slide.

Doctor. Primack: So what’s wrong? Why does this happen? We think if the brain is actually not getting enough iron. In medicine, we talked about some of called the substantia nigra, it’s a part of the brain. Most people know about that in Parkinson’s disease. Parkinson’s has too much iron in this area of the brain. This is actually not enough iron in this, and they’re both movement disorders. So, the substantia nigra is a part of the brain dealing with movements.

Doctor. Primack: Ferritin is one of the blood tests that we do, to measure the amount of iron in the body; it’s a storage form. There are other reasons that this can go up or down. Infection, inflammation, acute phase reactant. So if you’ve been very sick, and it can be up for four or five weeks. So, if you get the flu, or you get something like that, that’s not the time to check this test. It changes with age. It changes with your kidney function, also. You have to check those.

Doctor. Primack: Iron homeostasis, which means the body and the way we absorb iron is very, very tightly regulated. So it isn’t just, I can send you home with iron all the time. And so if your ferritin is less than 10, which means you’re iron deficient, you’re going to absorb about 20% of the iron that you take it orally each day. That’s a pretty good amount. But if it goes up to 50 to 75, you’re only going to absorb 1% to 2% of it.

Doctor. Primack: You really may need to get your serum ferritin over 200, which you’re not going to get from that, to increase the actual brain iron. What’s the side effects to taking iron?

Female: Constipation.

Doctor. Primack: Constipation, absolutely. And so, if you’re only getting one to 2%, you’re going to be taking it for 16 years before you have enough iron. The amount, when you can dose it, Iron Sulfate, 325 milligrams with vitamin C that helps its absorption, if you ferritin’s less than 75. If it’s more than 75, you need to do it IV.

Doctor. Primack: It’s hard to see from back there, but this is an algorithm that you can follow through to see how you treat restless leg. At the top it talks about, you have the four core features of restless leg. Make sure it’s nothing else, that it’s mimicking. Then you do blood tests, serum ferritin and some iron studies.

Doctor. Primack: And if they are low, and your serum ferritin is greater than 75, you can give regular oral iron. Do you do it for about 12 weeks, and you assess how people are doing. If you can’t give oral iron, or they’re not seeing the benefit then you can go down on the intravenous iron pathway. This is the whole intravenous iron, we don’t need to go through this particular slide.

Doctor. Primack: How do people treat it? Besides iron, medical therapy. There’s at least four drugs that we’ll talk about, that are approved. And several drugs that are not approved, that are also used. Ropinorole is called Requip, you guys have heard of that one? It’s approved in 2005 for restless legs syndrome. You see improvement in about a week, which is pretty good if you’ve had this thing for years.

Doctor. Primack: Side effects, everything we do has some potential side effects: nausea, fatigue, dizziness and headache. You start with a quarter milligram, and build up to a one to five. The problem with many of these medicines are two-fold. Some of them, we lose benefit. So about 13% of them, people lost the benefit of the medicine after a while. 4% of people saw augmentation, so the restless legs actually got a little worse with the treatment. But, 96% obviously did not.

Doctor. Primack: Mirapex, another very, very common medicine use for this, approved the next year after the other one, so 2006. Augmentation was seen and more of them 9.2, but actually up to 42% after you’d been on it for eight years. Some people got sleepy. This is a bad one, 10% of people develop impulse control disorders. Others needed other meds, to help it work.

Doctor. Primack: This one’s a patch, NEUPRO. Dose one to three milligrams for five years, but 50% of people stopped it because it wasn’t working. 13% of people had significant augmentation, but only 4% of them stopped it. So overall it was more effective than the others. And side effects were much less, because it was only local from the patch that you were putting on.

Doctor. Primack: Other medicines, carbidopa, levodopa, which is a movement disorder. So that’s actually, was a Parkinson’s disease drug. That was years ago, before these other ones came out. That was what we used as one of the potential things, but a lot of augmentation. A lot of people not getting the benefit, getting worse with it. Gabapentin has no augmentation, but in the world that we live in here, weight gain. So we don’t want that.

Doctor. Primack: Gabapentin or Horizant, another one that’s directly FDA approved. 300 milligrams in the evening, no augmentation seen, that’s a good one. But some somnolence or dizziness, other side effects. Opioids, so pain medicines. Percocets, Vicodins, and things like that. Methadone has been used for this.

Doctor. Primack: Clonazepam, which is in the Valium family. Carbamazepine, valproic acid and clonidine, all again, potentially used for this. A lot of people who have it, and have another reason to take one of these medicines, they can just take one of those instead. Or they tolerate them better than some of the others.

Doctor. Primack: Third part of our talk, now we’re going to start talking about things that we can do for sleeping. So first, if we think we have insomnia, let’s put a definition behind it. Yes, I’m having trouble falling asleep. I think it’s insomnia.

Doctor. Primack: Lie in bed for 30 minutes or more, three times a week for a month, that is the definition of insomnia. Or more often? Short term or chronic, and the leading cause of insomnia in women is anxiety. We wake up in the middle of the night thinking about stuff, that we can’t get out of my brain.

Doctor. Primack: So, let’s talk about sleep hygiene. This is one of the things, I talk about pieces of this all the time in the office. These are things you can do that are non-medicinal, that have been shown for a lot of people, to help them with sleep.

Doctor. Primack: The first one is light, avoiding blue light, especially. Blue light comes from screens all the time. If you have an i-product, so an Apple product, not the computer, but iPad, iPhone, there is something called Night Shift that you can turn on.

Doctor. Primack: There is a time you can turn it on from sundown to sunrise, and it knows where you are and such. So, it’ll do all of this for you. It puts a little orange tint into your screen, which isn’t making an orange; it’s actually taking the blue light out. Blue light turns off Melatonin, and that’s why we want to avoid that.

Doctor. Primack: On other, regular computers, so Apples or PC, there’s f.lux. If you Google that, it’s an APP that does the exact same thing. It’s free, and you can load it on any of your computers. It asks you what time zone you’re in, and you tell it and then it does it again, all for you. You don’t have to think about it.

Doctor. Primack: Clocks. You wake up at two in the morning, and what do you do first do? You look to see what time it is. And then you go, “Well, I only have two hours of sleep anyway, or three hours of sleep,” and you can’t fall back asleep. They’ve even said the light that comes out of the clock, even those little red numbers, if that’s what you’re using, are too bright.

Doctor. Primack: The recommendation is either get it out of your room, turning towards the wall, or what I used to do is, when I have a clock, is you put a little towel over it. If you really want to look at it, you lift it up and look at it, but it isn’t staring at you; you don’t know. If you wake up, and you don’t know if it’s 11:00, where you usually go back to sleep, or it’s 2:30, you’re like, “Yeah, I’m having a little trouble.” Don’t look.

Doctor. Primack: Number three, temperature. The optimum temperature for is somewhere between 60 and 67 degrees. Hard to get into in the summer months, here in Arizona. But fans and air conditioning, obviously, not so hard, not so bad sounds.

Doctor. Primack: Sounds. If you’re in a new place, you’re in a new hotel room and there’s different sounds, our Body reacts to that. If someone is snoring in the bed next to you, we react to that also. If you have pets and other things. Noise machines or something like that, do work very well for that. So that you always have a certain sound that your body gets used to knowing, “It’s sleep time.”

Doctor. Primack: Scents. If there is any scent that helps us sleep, it’s probably lavender. It hasn’t been studied, but it is definitely out in the literature that if you’re going to try anything, that one may help us with sleep.

Doctor. Primack: Cut off caffeine by, I always talk about 2:00 the afternoon, especially if you go to bed around 10:00. If you go to bed much later than that, use four in the afternoon, because caffeine interferes with sleep.

Doctor. Primack: Avoid alcohol, especially before bed. We fall asleep better with alcohol, we don’t stay asleep better. What it’s doing is, suppressing our REM sleep. So that’s why people wake 2:00, 3:00, 4:00, you’re waking up every hour, hour and a half after that drink earlier in the evening.

Doctor. Primack: Night showers or baths. So basically you’re doing something that’s heating up your body, and then as the cooling off process that helps us fall asleep. So, a hot shower, or hot bath, a hot drink that doesn’t have calories in it, a another good one. They used to talking about warm milk, and things like that.

Doctor. Primack: Meditate, taking those crazy brain thoughts and being able to turn them off. I talked, when we go to the gym, we work out in this muscle. When we meditate, we work out that muscle. There’s a lot of apps that are really good for that now. You can start out with just a little bit.

Doctor. Primack: Meditation is almost like what we talked, gardening. You have to keep watering and watering and watering and watering it. You don’t get your plant until months, and potentially years later. And meditation, you get your benefits over time.

Doctor. Primack: Routine to wind down, at the end of the day. I ask a lot of people, set an alarm. You keep missing, you know you should go to bed at 10:00, but by the time you look at the clock, it’s 11:30. Well, let’s set an alarm to go to sleep, not just to wake up. And then you set either, give yourself either 30 minutes or 60 minutes.

Doctor. Primack: Take that time divide it into three sections. The first section, anything I have to finish for today, load the dishwasher, things like that. What do I have to do for tomorrow, for me and my house? Let’s get my son’s lunch ready, or something like that. Something has to go to the office, it ends up in my car, or I forget it at home. That’s when they do those kinds of things.

Doctor. Primack: Then the third section is self-care. You brushed your teeth, you take your medicines, you start your sleeping process. If we set an alarm for it, it tells us when we should do that. When to stop Netflixing, or whatever we’re doing at that time.

Doctor. Primack: There’s a process called basically you’re tricking yourself. You’re actually saying, “Stay awake, stay awake, stay awake, stay awake.” You’re focusing on that, and you actually just drift off. It’s written up in the literature, as being an effective tool.

Doctor. Primack: I use an app called Pzizz. I’ve told many of you guys about that. It’s available on all the devices that we have. It is an app, and it’s a soundtrack for sleep. I put on an old iPod, and I listen to it. It’s always in one ear, the other ear’s against the pillow, to block out all the other sound. This is what I’ve been doing, for over easily over five years.

Doctor. Primack: Then there’s another guy, he’s a hypnotist, named then Rick Collingwood. I actually use that one to go back to sleep, if I happen to wake up. He has a weight loss hypnosis. I got it on Amazon as a download, years ago. He actually, I’m a cyclist, and he has one for being a better cyclist.

Doctor. Primack: So he’s giving you little subliminal thoughts, about that stuff. There’s for smoking cessation. He has a whole series of them. He’s Australian, he has a good accent. It puts me to sleep, all the time. And if I happen to wake up in the middle of the night, I just start it up again.

Doctor. Primack: My body knows when I hear either of those two things, it’s time to go to sleep. Because it’s been, again, if I said five years, I’m probably downplaying it back two or three.

Doctor. Primack: Then, progressive relaxation. Start at the head tense your neck, tense your shoulders, tense and your arms, working butt slowly all the way down, and take about a minute to a minute and a half to go through that. Then, if it doesn’t work, you do it again. Absolute, be sure to do that.

Doctor. Primack: Melatonin, a hormone and I talked about a fair amount. It comes from the pineal gland, it’s about the size of a grape, in the back of our brain. We all have Melatonin, it is our sleep hormone. At wake, during the normal part of the day, it’s very light. You only have about one picogram per milligram, a very low amount.

Doctor. Primack: At 15 hours later, increases to 10. About two hours before we go to sleep, it’s rising, starting to get our bodies ready to go to sleep. It rises at its peak to 60-70, at about 3:00 in the morning. In the morning when we see daylight, it brings our melatonin back down.

Doctor. Primack: That’s why getting dark in the evening light in the morning, I tell a lot of people who I think that they have a melatonin thing. Sitting in your kitchen, facing the windows in the morning for about 15 minutes. The outside, go for a walk outside without sunglasses, about 15 minutes, and get that light in to turn off your melatonin.

Doctor. Primack: Melatonin works on two parts of our body, that work on sleep. The first part, and it’s called a weak hypnotic. Hypnotics are medicines that put you to sleep, or work directly on the sleep process. It works on a system called the adenosine system. When we wake up in the morning, adenosine’s low, and the longer you stay awake the higher adenosine gets.

Doctor. Primack: If you woke up at 7:00 in the morning, and try to go to bed at 9:00 in the morning, your adenosine’s really low, it’s really hard to fall asleep two hours later. You stay up for 24 hours, if your adenosine’s high enough, you could probably fall asleep, standing up, almost. Stay up for 48 hours, and you’re falling asleep, micro-sleeping all the time.

Doctor. Primack: Taking a nap at the wrong part of the day, you took a nap at 5:00 PM and you’re going to go to bed at 10:00, it brings your adenosine levels down just enough, so that when you tried to go to sleep later, they’re not high enough. So, melatonin does not work very well on that system.

Doctor. Primack: But what it does work very good on, is a chronobiotic. What it’s doing, is helping reset your internal clock, to tell you that it is that time. So some people say, “I should go to bed at 10:00, but I’m never tired at 10:00.: We start using Melatonin, and we start using it … and I talk, I think on the next slide, about when we should start using it. But it’s actually not at bedtime, it’s much before that.

Doctor. Primack: What’s the right dose? If you go to the grocery store, you see once you see threes, fives, 10s. But the right dose at the blood level, is 0.3 milligrams. At the oral level, it’s probably only one to three milligrams. But we’re taking way, way, way too much of it. Because, as we talked about, it was picograms, were the actual dose that we had in our body.

Doctor. Primack: Best time to take it, forward setting your clock, nine hours after you get up or seven hours before sleep, telling your body. Especially, if you travel across time zones, you can use this to help you get reset on the new time zone. Especially, if you’re going over oceans. So, more time zones away.

Doctor. Primack: How much light does it take, or what wavelength of light does it take to suppress Melatonin? Blue light in the 440 to 460. You can actually buy that, I did buy a pair of … I’ve only worn them twice, so I can’t tell you that they work. But these orange, blue blocker sunglasses that you wear around your house in the evening. I had all these ideas of wearing them, and I actually haven’t; they sit on my night stand. I was going to try it out, but you can buy those. They’re very inexpensive.

Doctor. Primack: I’m not going to go through this whole chart, but this is a whole chart put out by the American Academy of Sleep Medicine. It’s what to do, with medicines for sleep. 14 of them were listed. Just to talk about them, Belsomra is a new prescription in the last couple of years, for sleep. Lunesta, a lot of us have heard of. It’s a very common one. Sonata is very short acting, so it helps you fall asleep; it doesn’t help you stay asleep.

Doctor. Primack: Ambien, the one that’s been out forever. We do know that Ambien, especially and Lunesta in some people, so you have to be very careful. During the night they do things, and eating is one of them. Back when I first heard about this, I actually didn’t believe it. I had a patient, before he started doing weight and he walked into my office at 10 minutes to eight for a sick visit, and he had a big burn on his arm.

Doctor. Primack: He came in with his wife, and I said, “What happened?” And his wife goes, “Every time he takes his Ambien, he cooks bacon at 3:00 in the morning.” He got grease spilled on his arm that night, and we treated him for second degree burns. And we worked to get them off his Ambien. Triazolam, temazepam, are in the Valium family. Rozerem, another one, and Doxepin.

Doctor. Primack: Now, it’s interesting they say, ones you should not to use. Very commonly used Trazodone, one we even use here. Diphenhydramine, what is that?

Audience: Benadryl.

Doctor. Primack: Benadryl. There is a weight gain property to Benadryl. You do have to be careful with that one. What they’re saying is, for chronic use. You have to use a Benadryl here and there, go for it. But it’s for everyday use, we probably have better medicines for it. Melatonin for sleep onset. They’re saying, as we talked about, [inaudible 01:03:34]. For resetting the chronotrope, it was for very good.

Doctor. Primack: Valerian, some people use, they’re not recommending. And then Tryptophan.

Female: How many of those at the top or not addictive, but you have to rely on them in order to sleep?

Doctor. Primack: The majority of them. And that is one of the reasons they’re avoiding and trying to avoid some of these medicines.

Doctor. Primack: I believe you should work on sleep hygiene first. If you get to a point where you’re just still not sleeping, you do need to consider these. Because it’s better to be, call it-

Female: Asleep.

Doctor. Primack: … addicted to a medicine is only helping you sleep, as long as you’re not having the nighttime … o they go through, eating is one of them. Back when I was asking him questions, I had over 100 people, once I got up to about 100, I stopped counting.

Doctor. Primack: I’ve had people drive their car in their sleep. Someone pulling their cars in the driveway, because they forgot to pull it in, and went into the cabinets. In the morning she said to her husband, “Who pulled my car in the garage?” He said, “You did.”

Doctor. Primack: In the last six months, I had someone cleaning their chandelier over their dining room table, which they said they would have never done. Beyond that, one of the first people ordered when Amazon was new, she knew all of her stuff to get in. It wasn’t the one-click ordering. She ordered 10 of the same book, and was too embarrassed to send it back. I know people, Facebook, they instant message, they do all that kind of stuff in their sleep.

Doctor. Primack: I think infomercials probably are only around so that people buy things in their sleep. That’s my guess.

Female: Can I ask one more question?

Doctor. Primack: Absolutely.

Female: Why not Benadryl?

Doctor. Primack: For me, it’s about the weight gaining properties. It’s an H1 blocker, they call it, and that system works a little bit on appetite. And the fatigue that some people get, the hangover that they get, will cause you want to use carbs more to bring up your energy if you’re hung over from it. But again, episodic use, you need it once here and there, go for it. Every night, you probably should find something else.

Female: What about the zolpidem, I’ve been told that in the Lunesta, Alzheimer’s research.

Doctor. Primack: I have not seen it. I can’t really comment on it.

Female: Okay.

Doctor. Primack: I’ve heard buzz, but they’re still on the market. If they truly were causing it, they’d come off the market. That’s my belief.

Female: Okay. I like that.

Doctor. Primack: I’m simple. Last couple of slides. So the WHO, the World Health Organization, and the CDC recommends seven to eight hours of sleep per night. How do you get seven, eight hours of sleep per night. If the average person’s sleep efficiency is about 90% of the time you lay in bed, including waking up. Waking up for bathroom, that we go through 90 minute sleep cycles. To get eight hours, you need eight and a half hours in bed. To get seven hours and 12 minutes, you need to be in bed for eight hours.

Doctor. Primack: So we can’t just, get in bed at 9:00, and get out of bed at 4:00, and say we’ve had all the sleep we need. We need a little more than that, because of some of the inefficiencies. If you’re drinking the amount of water that I ask you to drink, you’re waking up one, two or three times a night. Hopefully going right back to sleep.

Doctor. Primack: Last but not least, a quote from one of the studies. “Sleep is the most sedentary activity. Yet, maybe our only sedentary activity that protects you from weight gain and improves your health.”

Doctor. Primack: Thanks.

Doctor. Primack: Questions?

Female: All right.

Doctor. Primack: Go ahead.

Female: I’ve been doing Fitbit, and it talks about deep sleep and REM sleep. So, I started doing some research and I was reading that deep sleep is better than REM. What actually is-

Doctor. Primack: Sleep goes through, there’s phase, one, two, three, four REM sleep. It goes through a 90 minute cycle, and you need all of them, truthfully. You need light sleep, you need deep sleep and you need REM sleep. If you’re not getting as much deep sleep, then something is interfering you from getting into that deep sleep. Whether it’s movements, whether it’s snoring in the same bed, whatever it is.

Female: Or my own snoring.

Doctor. Primack: Or, yeah, or something.

Male: So you could achieve REM sleep several times during the night?

Doctor. Primack: Yes. Another part about getting short sleep, so five or six hours, if it goes by 90 minute cycles, and you have more REM sleep in the later parts of night. So, if you take 90 minutes, 90 minutes, 90 minutes, at five or six hours, you’re missing the whole cycle of sleep.

Doctor. Primack: So, when people say, “I tend to wake up at 3:00 in the morning,” is because probably for their timing it happens to be at a top where they’re in a light stage of sleep. Then you notice your bladder’s full, so you wake up. And I say, you didn’t reset. For me, it’s always on the right side with that little earbud in.

Doctor. Primack: I actually, personally, again, I sleep with a sleep mask even in the dark room that I’m in. I just got used to it a couple of years ago, when there was a time where it wasn’t dark. And so, that sensation again, so I am super programmed when it comes to sleep.

Doctor. Primack: Yes.

Female: With the CPAP machine, how long should it take for you to fall asleep on the average, using that machine?

Doctor. Primack: It’s going to be different for every person. The newer machines start off the pressure very low, to allow you to comfortably, or more comfortably fall asleep. Then over the next half an hour to an hour, ramp up the pressure to where it should be.

Doctor. Primack: More often, it’s someone who’s mask or such, doesn’t fit them correctly, or is not comfortable. And I’ve had many, many, many people have to do five, and six and seven different masks, before they found the one that was comfortable enough to then fall asleep. But, to say we don’t have insomnia, we want to not lay there for more than half an hour. Hopefully, less than half an hour.

Male: Once you get used to it, you can just whap it on, go right into a coma.

Female: Two hours, and I throw the thing across the road. Say, “That’s it, I’m not doing it any longer.”

Doctor. Primack: You may benefit from one of the medicines that were on the list, [crosstalk 01:09:49] to help induce sleep.

Female: I want the old one back.

Doctor. Primack: Yeah.

Male: What about naps? You never discussed naps.

Doctor. Primack: I think naps are mixed piece. If you can nap, and still go to sleep at your normal time, I think naps are good. I think for most people, we nap too long when we down. The average nap should be 20 or 30 minutes, just to take the edge off of that, and then go right back to what you’re doing.

Doctor. Primack: So again, with that Pzizz app, there’s two modes. There’s a sleep mode and a nap mode. And in the nap mode, you can set it for 20 and 30 minutes, and it actually wakes you up. Over the years, now, when I … I’m a napper, I have never overslept from that thing. It’s a guy’s voice, and he talks for a few minutes, and then it gets quiet. Then right before, it goes, “Now wake up, and have a great day.”

Doctor. Primack: I can tell you he talks for six minutes, and I’ve listened to it a thousand or more time, I still don’t know what he says. It’s just so subtle, and so forth. I did have someone, I do call him creepy. I still think the app is great.

Doctor. Primack: So yeah, napping, as long as it doesn’t interfere with your asleep. The earlier in the afternoon, the better. The 1:30, 2:00, as opposed to the 4:00, for sure. Always better. If you’re not getting it at, hopefully you can get a little nap to catch up. during the day a little bit. A study just came out … the five doctors in the practice, we get together once a month, every month, six weeks, and we do a little journal clubs. So everyone prepares an article.

Doctor. Primack: We just had one last night, and Dr. [Guzman 01:11:26] did one on sleep. It talked about how you could not catch up on sleep, on the weekends. We’ve talked about it. It’s gone back and forth, and back and forth. It isn’t that, if you just miss for one night and then one weekend, and you catch up on the weekend and then you go back to sleeping normally. It was really when you lost sleep during the week, you caught up on the weekend, and then went back into losing sleep on the next week. That was when you had the detriment.

Male: That messes up your sleep hygiene.

Doctor. Primack: It does mess up your sleep hygiene. That messes up your internal clock, of when you should be sleeping in and not. I didn’t talk about it, but I guess, the time you go to sleep should, as close as possible, be within the same hour, seven days a week; weekends and weekdays.

Doctor. Primack: There’s this thing called social jet lag, which is when you stay up actually late on a Friday and Saturday, and then Sunday night comes and you’re trying to get to sleep to go to work on Monday, and you can’t fall asleep. It’s not jet lag because we’ve flown, it’s jet lag because we’re not keeping and listening to our internal systems.

Doctor. Primack: Caffeine works on that adenosine system, and that’s why caffeine is our world’s most used drug.

Doctor. Primack: Yes.

Female: If you’re up by 5:00 or 6:00 every morning, are you in bed usually, by 9:00 or 10:00- [crosstalk 01:12:45]

Doctor. Primack: I am asleep before 10:00 100-almost% the time. I’m probably in bed by 9:30, 9:20, 9:15. The perfect night is asleep by 9:30, 9:35. Because I’m up at 10 to five or 5:00, almost seven days a week. It works for me. Doesn’t work for everybody. Other questions.

Female: When do you get your nap in?

Doctor. Primack: I slept for 15 minutes right before came here.

Doctor. Primack: Yeah, we started at 6:00 this morning, so I went home and took a very short one.

Doctor. Primack: All right? Well, thanks everybody.


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