Season 4 | Episode 2
Title: Sleep
Guest: Dr. Richard Schwab, Chief, Division of Sleep Medicine Professor of Medicine at the Hospital of the University of Pennsylvania
Dr. Richard Schwab: Everybody take a breath through your nose, just breathe through your nose. And now take another breathe through your nose, but push your nose up, just a little bit and you and you should find that it's easier to breathe when you pushed your nose up, because we all have these nasal valves. And that's how these breathe-right strips or these different strips work, they open up the nasal valve, but has nothing to do with sleep apnea.
Joe McIntyre: Welcome to the Merck Manuals Medical Myths podcast, where we set the record straight on today's most talked about medical topics and questions. I'm your host Joe McIntyre. And on this episode, we welcome Dr. Richard Schwab. Dr. Schwab is a professor of Medicine at the University of Pennsylvania in Philadelphia, where he is the chief of the Division of Sleep Medicine. And as you might guess, catching zzz’s will be the focus of today's episode. Dr. Schwab. Welcome to the show.
Dr. Richard Schwab: Thanks, Joe.
Joe McIntyre: Now, there are a ton of missed questions and even misunderstandings when it comes to sleep. How much sleep do we need? What happens when we sleep? And what happens when we don't sleep? But first, let's start off with a question that I'm not sure many of us even know the answer to Dr. Schwab. Why do we need sleep?
Dr. Richard Schwab: Well, you're correct. And we don't know the answer to that question. There's a lot of hypotheses, including that it, it creates restoration, your body sort of restores itself, it gets rid of sort of junk that's in the brain, it helps consolidate memories. But we really don't know. On the other hand, every mammal we know of sleeps, so it has, obviously an incredibly important function, we spend at least a third of our time sleeping. So, it's clearly important, but we really don't know the answer to that question as of yet.
Joe McIntyre: Now, is it true that you need eight hours of sleep exactly, to be fully rested, and, you know, are people who say they only need a few hours of sleep wrong? What's the case there?
Dr. Richard Schwab: So, it's very individual, most people need seven and a half to eight and a half hours of sleep. But it's a bell-shaped curve. So, there are people on the far end who can get by with four to five hours of sleep. On the other hand, there's people in the far end of that curve who need nine to 10 hours, or 11 to 12 hours of sleep. So, there are people who can get by with a shorter amount of sleep. But that's the exception. For most of us, we need seven and a half to eight and a half hours of sleep.
Joe McIntyre: Now, for let's say maybe new parents who are struggling with reduced sleep, and even others who feel they don't get enough sleep in general, does your body eventually get used to sleeping fewer hours each night?
Dr. Richard Schwab: Not really. So, you develop chronic sleep deprivation, and then you can fall asleep driving or you won't perform well at work. Now you can catch up on your sleep so you can catch up on the weekends. And that's what most of us do, we get sleep deprived during the week and catch up on the weekends. And one of the reasons that people drink coffee is to keep them awake, because we're chronically sleep deprived. But you can't get by with less sleep, it's going to affect you one way or another. So that doesn't work, you can again bank it, you can catch up on it. But chronic sleep deprivation is not a good idea.
Joe McIntyre: Now, let's say you're having difficulty falling asleep one night, for whatever reason. Is it best to stay in bed until you fall back asleep or get out of bed and do something else in the meantime?
Dr. Richard Schwab: Really depends on what you are. If it only happens once, maybe it's fine to stay in bed. But for the most part, if it's more of a chronic problem, you want to get out of bed, go to a quiet corner, read a sort of adult book, wait till you get sleepy again and go back to sleep. People can get frustrated in bed, if you can't sleep and you just sort of sit there and you start getting angry, you start looking at the clock, which is a bad thing to do, never look at the clock turn the clock the other way, but in general, one night of sleep deprivation isn't going to be bad. And you'll usually sleep fine the next night. But if it's more chronic, you want to get out of bed until you get sleepy again.
Joe McIntyre: Is there an ideal temperature for maximizing the best sleep possible? Is it better to be cold or warm? What's that exact temperature that you should be at? If you can, if you can make it happen?
Dr. Richard Schwab: Yeah, I don't think there's good science to answer that question is a lot individual. But as a general rule, colder is better for most people. But again, that's not everybody. And typically your bed partner what may like a certain room temperature and you may like a different room temperature or you want more covers or not. So, it can become complicated, depending on who your bed partner is and what their needs are.
Joe McIntyre: Now, you mentioned this a little bit earlier, but you're saying when it's the weekend and we get the opportunity to sleep a little bit longer, we can actually quote unquote make up for lost sleep during the week. Is that actually the case? It's not where, you know, you can't actually make up for that lost time?
Dr. Richard Schwab: No, you can make it up. Ideally, it would be best not to make it up. If you had your best situation you'd always go to bed at the same time always get up at the same time your body gets used to it, but most of us can't do that we're not getting enough sleep during the week, and so you catch up on the weekends and you sleep in. That's a good idea. And for most people, when they go on vacation, they may be very sleep deprived. And it can take a week or two for them to really recover, but they can recover. So, I do think you can make it up. But you have to have the ability to make that up. If you're working every day of the week, you're not going to be able to catch up.
Joe McIntyre: Now, for those of us who sometimes have trouble falling asleep, you've all heard the wives’ tale of counting sheep to help yourself fall asleep, does that or something similar actually work to help get people to fall asleep?
Dr. Richard Schwab: So again, there's not a lot of science behind counting sheep, but focusing on something that your brain can just become subtle and monotonous and it's not something where you're really actively thinking about something, that's a good idea whether you're tapping your finger, whether you're counting numbers, you know, counting back from 100, counting sheep, it's kind of just dulls your brain. You just don't want to be able to do something where, “Oh, my gosh, what do I have to do today? What am I going to do? I have to have this. This, this, this, this and this has to get done. I'm not going to get it all done.” And so the less you activate your brain, the better. So, I think counting sheep, actually, from that standpoint is probably a good idea.
Joe McIntyre: Let's say, you usually wake up around seven o'clock in the morning, but you don't need to get technically out of bed until 730, is hitting snooze every morning a bad thing? Is it okay? What is your perspective there?
Dr. Richard Schwab: It's a terrible thing. You should never ever hit the snooze button. Because that wakes you up. And so, you might have been in REM sleep, rapid eye movement, sleep or dreaming sleep. And now that alarm knocked you out of that sleep, which is restful, really important sleep. So, the message is never use the snooze button set the the alarm for the last possible moment and once it goes off, get up. Do not ever use the snooze button.
Joe McIntyre: Very interesting. Okay. Let's say you want to have a coffee, we're recording this at one o'clock in the afternoon. Let's say you want to have a coffee around three, or even after dinner, say seven or eight o'clock. Does having a coffee with caffeine in it too late in the day affect your ability to sleep?
Dr. Schwab: For most people, it will. For people who are chronically drinking coffee, I don't think it does. But for most people, caffeine has about a half-life of 12 hours. So, you don't want to drink coffee pretty much after lunchtime. Especially, if it's intermittent. If it's again, it's someone who's chronically drinking coffee, they may get acclimated to it and it won't matter, but someone who's not used to that I would not recommend caffeinated coffee at dinner even really after lunchtime.
Joe McIntyre: Interesting. Now, we all have different preferences when it comes to exercise. Some people like working out in the morning super early, some people prefer the afternoon, some people it’s in between. Does when you exercise have any effect on how you sleep? Is it better to exercise in the morning or night when it comes to your sleep health?
Dr. Schwab: There's no right answer there. Except you don't want the exercise to affect your sleep or your sleep time in any way. So, if you have to get up early, you're getting up at five in the morning to exercise and you don't go to bed early enough. Well, now you're going to be sleep deprived. And so that's a bad idea.
You also don't want to exercise close to bedtime, because it's going to make it hard for you to fall asleep. So you want to exercise. Within two hours of sleep, you do not want to exercise. But pretty much the rest of time, it doesn't matter. I think the easiest time to exercise is probably when you get home from work if you're on a normal schedule before you have dinner. But that's not easy either. And obviously, exercising on the weekends is easier. But I don't love getting up early in the morning to exercise. Because I think unless you're going to bed early enough, you're going to lose sleep on that end. And again, exercising close to bedtime is a bad idea. That all being said exercise is a really good thing to help you to sleep, especially with insomnia because it makes you more sleepy, more tired. So, I really like exercise for lots of reasons, but you do need to time it appropriately.
Joe McIntyre: Now let's get into a little bit of the foods that we eat or the foods that we drink and how that affects our sleep. So let's say you go out for a couple of drinks after work or on the weekend, is sleep after a night of drinking bad sleep? Is it a good sleep? And, you know, some people have an easier time falling asleep after consuming some alcohol. But is it actually a restful sleep?
Dr. Richard Schwab: No, alcohol is really bad for sleep. It does put people to sleep. So it puts you to sleep but then it fragments your sleep so you'd be up all night. Or you may not wake up but your sleep is going to be fragmented. And one of the reasons people feel sort of a hangover the next day isn't necessarily the alcohol. It's partly the alcohol but it's also partially that your sleep is fragmented from the alcohol itself. So alcohol is really bad for sleep. Again, nobody can do this, but if you had a drink at lunchtime, rather than dinnertime and it was out of your system by the time you went to sleep that would be fine. But alcohol, any time period close to your sleep period, is a bad idea.
Joe McIntyre: Now how about generally eating towards the end of the night. Does eating too late at night before we have to go to sleep affect our ability to get actual restful sleep again?
Dr. Richard Schwab: Not necessarily, but it does partly depend on what type of food you eat. So, if you eat a food that can cause heartburn or reflux, and then that's going to wake you up, that's a bad thing. And if you probably ate too much food before you go to bed, the carbohydrates is going to rev you up. So that's a bad thing. But you also don't want to go to bed hungry. Because if you go to bed hungry, you may have trouble and that may wake you up. So ideally, not too much food, a little bit of food before bedtime is probably fine. And then staying away from anything that's going to cause heartburn, because that could wake you up.
Joe McIntyre: Now how about cannabis? Some people swear by cannabis and its ability to help them fall asleep. Does that have the same effect as alcohol where experiencing or doing cannabis before bed does not give you that same type of quality sleep?
Dr. Richard Schwab: So, we don't really know as much about cannabis as we do with alcohol. Alcohol clearly fragments your sleep. Cannabis? It's really good for pain. And from that standpoint, if you have chronic pain, you may have trouble sleeping. So, I think cannabis for someone who's got chronic pain is a really good idea. The one thing about cannabis that I worry about is that when you come off of it, the patients often develop pretty significant insomnia. So, if you're using cannabis on a short-term basis, you need to plan for the fact that when you come off of this, that sleep may be difficult to achieve because of insomnia, but its effects, otherwise, haven't been super well studied. I don't think it's bad. I will tell you that you shouldn't be smoking marijuana. I think if you're going to do this, edibles is the way to go because you don't want to affect your lungs. But I think cannabis in general, especially in people with chronic pain, is a good thing for sleep.
Joe McIntyre: Good to know. Now how about sleep medications for those folks who have chronic insomnia, like you mentioned, they may want to turn to some medications or prescriptions to help them get to sleep. Are all sleep medications harmful? We've heard some horror stories, but what's the what's the science behind that?
Dr. Richard Schwab: Yeah, for most, for the most part, sleep medications are harmful. The one that probably isn't totally harmful is melatonin, especially at lower doses, because it's a naturally occurring hormone. So it doesn't really get you into as much trouble. It doesn’t often work super well. And if you’re going to take it, usually take it about an hour before bedtime. All over-the-counter sleeping pills have Benadryl in them. And Benadryl has got a very long half life. , It's never been shown to be a good sleeping pill. It's basically an antihistamine, it puts you to sleep, it's a really bad choice. And all the prescription medications, they're also bad. They're designed to be used for six weeks, but people stay on them forever. They have memory effects, they have fall risks. One of the issues is that you take a sleeping pill, and you walk to go to the bathroom. Now you have the sedative onboard, you trip on the carpet, and you fall and hit your head or you break your hip and you can die from that. So sleeping pills in general, really bad idea. The way we treat chronic insomnia is something called cognitive behavioral therapy. It's counseling to teach you how to sleep, sleep relaxation techniques, sleep hygiene techniques, they make your sleep more efficient by reducing it and keeping a sleep diary. So, for the most part, I don't recommend sleep medications at all anymore. In fact, I take people off of sleep medications, I do that much more than actually starting them.
Joe McIntyre: Now, let's say you're getting ready to go to bed, you hop in bed, you put your phone on your nightstand to charge, and then you spend 25-30 minutes looking at your phone before you fall asleep. We've all heard some of the rumors that looking at your phone and its blue light is bad for your sleep health. Is that actually the case?
Dr. Richard Schwab: The bed should be used for sleeping. Really nothing else. You should never do any work in the bed. You shouldn't be really watching TV, even in the bed and flicking your phone or working or looking at your computer independent of the light effects are a bad idea. Because you just get in this habit of "okay, I'm not associating the bed with sleeping." And that's really what you want to associate with. But anything that's going to cause blue light, it's going to activate you, it's going to wake you up, so no. No, leave the phone downstairs, turn it off. Don't look at it in bed, don't bring your computer into bed. Use the bed for sleeping.
Joe McIntyre: Now, let's say it's Sunday afternoon. It's a beautiful day outside, the windows are open, you decide to doze off on the couch for 30 minutes or 15 minutes or maybe even an hour. Does a nap in the middle of the day ruin your sleep cycle at night?
Dr. Richard Schwab: So, most of us are sleep deprived. So, the answer is no. I think if you weren't sleep deprived, maybe. And so if you went on vacation and you're fine. And you're getting enough sleep and taking a nap, assuming you're maybe in the second week of that vacation because the first week you're probably still sleep deprived, then it might affect your sleep. , But for most of us because we're sleep deprived, a short nap isn't going to do anything to hurt you.
Joe McIntyre: Now, when it comes to our bodies and how we actually sleep, whether it's back, side, stomach, is there a preferred way to sleep from your perspective?
Dr. Richard Schwab: Typically, on your back may make you start to snore or cause sleep apnea. So from a sleep apnea standpoint, back sleeping is not a good idea. The side or stomach is fine. Some of that may depend on how your back feels in those different positions. And some people feel better on their stomach or their side. But in the supine position, on your back, that's a risk factor for sleep apnea. So typically, especially if you're heavy, you don't want to sleep on your back, but the other positions are fine. I think it's patient preference.
Joe McIntyre: Is talking in your sleep a sign of another more serious health condition? So, let's say you're babbling along in the middle of the night, is that a sign that you should have something else checked out about your health? Or could that just be someone's way of sleeping?
Dr. Richard Schwab: If you start screaming in your sleep, or you're acting out a dream, or you get out of bed and start to sleepwalk, those are different stories. You have to protect the bedroom if that happens, but actually just talking in your sleep, not a problem. The only downside is that it might wake up your bed partner and disturb their sleep a little bit, but it's not going to affect you in any adverse way.
Joe McIntyre: I do know that you are quite a bit of an expert when it comes to sleep apnea. Do breathe strips actually work to stop someone from snoring or prevent someone from suffering from sleep apnea? Or do more severe and more serious methods need to be used to prevent sleep apnea?
Dr. Richard Schwab: No, they don't work. So for the audience, everybody take a breath through your nose. Just breathe through your nose. And now take another breath through your nose, but push your nose up just a little bit. You should find that it's easier to breathe when you push your nose up because we all have these nasal valves. And that's how these Breathe Right strips work or the different strips work, they open up the nasal valve. But it has nothing to do with sleep apnea. Sleep apnea is something back in your pharynx, usually behind the soft palate or the base of the tongue, and the airway is too narrow back there. And that's why you collapse your airway and it closes. But the Breathe Right strips don't do that. And so they really don't work well at all. And although they're inexpensive, I wouldn't waste your time spending money on them.
Joe McIntyre: Dr. Schwabe a lot of us, I'm sure, either know someone who snores, has snored before, or does snore regularly. You were talking a little bit offline that snoring in general, just the idea of snoring is actually not normal and is a sign of a more serious issue. Can you talk a little bit more about that?
Dr. Richard Schwab: Yeah, if you’re snoring it really means there's something wrong with your upper airway, it gets narrow. And if that's the case, you should be potentially evaluated for sleep apnea, because that obviously has multiple complications, adverse consequences related to sleep apnea. There’s some data on the relationship of snoring to stroke. And the reason that occurs is that when you snore, because it's a vibration to your upper airway and that causes trauma to the carotid artery, which is up in your neck. So, you're snoring and get this vibration and maybe there's even issues about snoring and its relationship to stroke. We don't know that for sure, but clearly snoring is a risk for sleep apnea, and you should be evaluated, especially if you're sleepy. And just to remind the audience alcohol makes snoring worse. So, you do not want to drink, independent of its ability to cause sleep fragmentation.
Joe McIntyre: Now finally, what are some of the methods that you do recommend for someone who is suffering from sleep apnea? What should they do? If they do suffer from it, who should they go see first? And what are some of the ways that you work with your patients to solve those issues?
Dr. Richard Schwab: Right, so firstly, what are the symptoms of sleep apnea. So first, the most common one is snoring. The second most common one is daytime sleepiness. So, if you have either of those different things, you should be evaluated by a sleep specialist for sleep apnea. Typically, you're going to need a sleep study. The primary risk factor is obesity. It's not the only risk factor but if you listed 10 risk factors, obesity would be the first eight. The other ones are where your jaw is back, something we call retrognathia. And when we have recessed chin, it makes your mouth small. And then just so everybody knows alcohol also worsens snoring and worsens apnea. If you don't drink alcohol, you may not snore. Once you drink alcohol, you may become a snorer. And snorer who drinks alcohol may become an APNIC. And an APNIC who has alcohol, their apnea will get worse. But there's simple treatments for sleep apnea, sometimes its position where you just sleep on your side and your apnea is resolved. And there’s CPAP, which stands for continuous positive airway pressure. It's a little mask you wear over your nose that works as a pneumatic splint to open up your airway. It basically just vents open your airway. There's oral appliances that are designed to pull your jaw forward. Because the base of your tongue, the part you can't feel, inserts into your jaw. So if you move your jaw forward that will open up the airway. And then there's surgery for more refractory sleep apnea. And there's now something called hypoglossal nerve stimulation, which is basically a pacemaker for your tongue and it pushes your tongue towards your lips. So, there's lots of different treatments for sleep apnea. And once they're treated, they feel like they've had a brain transplant. They're no longer sleepy, then their blood pressure may get better. And just treatments of apnea will help prevent heart attacks and strokes and high blood pressure and atrial fibrillation and cardiac arrhythmias. So, there's lots of reasons to treat your apnea and you obviously don't want to have any of these medical complications. So, it's a great thing and it's easy to treat it. So, I would encourage anybody again, who is sleepy during the daytime, and they snore, and especially if you're a little bit overweight, to get evaluated for sleep apnea.
Joe McIntyre: Now, Dr. Schwab, as we close out this episode here, I want to give you a chance to let our listeners know of some places they can go if they have questions about their sleep health. If they have questions about one of your specialties, sleep apnea, where should our listeners go to find out answers about improving their sleep health or just sleep health in general?
Dr. Richard Schwab: So, in general, I think going to see a sleep physician, wherever you live, is a good idea. Go to a sleep center, potentially an accredited Sleep Center, you can come to the University of Pennsylvania, the Sleep Disorder Center there, you can see me are some of the other physicians. So, I think that's a good idea. If you're looking from a publication standpoint, the Merck manual is an excellent source. You'll get lots of information there and we'll be able to answer most of your questions about your sleep conditions.
Joe McIntyre: All right, well, Dr. Schwab, I want to thank you again for joining us on the Merck manuals medical myths podcast. It's been a pleasure to talk to you and I hope our listeners certainly learned something, so I'll leave them with something we say at the end of every episode at the Merck manuals.
Dr. Richard Schwab: Medical knowledge is power. So, pass it along.
