Welcome back! This is Part 3 of our series on sleep. In Part 1 we explored the nature of sleep, why it's important, and how much we need. In Part 2 we looked at what can go wrong with our health if we don't get enough sleep.

So far we've covered that sleep is essential and critical for memory consolidation, learning, tissue healing, and growth. We need about eight hours of quality sleep to avoid any negative effects of sleep deprivation, and those ramifications are indeed frightening: reduced physical, intellectual, and emotional performance, and increased likelihood of brain disease, inflammation, diabetes, obesity, heart trouble, and cancer.

While the average American is sleep deprived, clearly you're above average (to wit: you're reading this blog). Still, all of us have trouble sleeping occasionally if not regularly.

What can we do to get more and better sleep?

Actions you can take to improve your sleep fall into two broad buckets: sleep hygiene and sleep therapy, where hygiene prevents problems, and therapy treats problems.

Sleep Hygiene

The word hygiene probably conjures images of people neurotically washing their hands, and indeed is most often associated with body cleanliness. However, the actual definition of hygiene is broad: practices conductive to the preservation of health. Therefore, sleep hygiene isn't "clean sleep," but a set of practices that promote healthy slumber. In fact, many sleep specialists categorize inadequate sleep hygiene as a sleep disorder that deserves intervention.

Go to bed!

At the risk of making you roll your eyes and stop reading, perhaps the simplest solution is to go to bed. We have a 24-hour society now, and "social exhaustion" is actually a thing. FOMO (fear of missing out) keeps us checking our devices for the latest text, email, or Facebook post. Netflix releases entire seasons of our favorite shows at once, making it possible to binge on 10 hours of TV by staying up all night. We have quite literally banished darkness with the invention of interior light, making it easy and safe to wander the built-world after dark. Some estimate that our total sleep has decreased by a third since the invention of the light bulb.

For the vast majority of us, our schedules are determined by the time our commitments start during the day, whether this is when you have to be at work, at school, or care-taking kids. Determining your bed time is simply backtracking from the time you need to awake till the time that, if you fall asleep reasonably promptly, you'll get roughly the recommended eight hours of sleep. To those of you with early-starts (I'm looking at you, parents of kids in high school that need to catch an early bus), this means you have to go to bed laughably early. If you have to get up at 6am, you should be in bed by 10pm. That means your wind-down routine must start between 9 and 9:30pm. That means sacrifice, fighting FOMO, and perhaps experiencing embarrassment when somebody asks you when you go to bed.

This one issue—going to bed early enough to get sufficient sleep—is a major barrier for most people. A lot of activities happen in those prime time hours, such as dating, good TV shows, going out to dinner, homework and studying, etc. Many people will use the phrase "I can't go to bed that early." But what they are really saying is "I won't go to bed that early, and I choose my social life and entertainment over quality sleep." The truth hurts.

I put this at the top because it is the one thing that most people do not do that will have the biggest impact on sleep. The rest of the suggestions below are important, but if you're still getting less than the recommended amount sleep, you're slowly killing yourself (see Part 2).

So go to bed!

Make your bedroom a sleep sanctuary

Do you remember the Seinfeld episode where Jerry and Kramer switched apartments? There was an obnoxious red light coming in through Kramer's windows, keeping Jerry awake at night and making him slowly but surely lose his mind. Kramer calmed down the longer he slept in Jerry's bed. In fact, they started to switch personalities!

If your bedroom is like Kramer's, you've got a problem. Your bedroom needs to be a sleep sanctuary.

So how do you go about making your bedroom conductive to sleep? First, use it only for sleep (and, when you're lucky, sex). Don't let your bedroom be a multi-purpose room. Remove all the electronics: don't watch TV, use your laptop, your tablet, or iThings in bed. Don't even read a paper book in your bed. The idea is twofold: removing distractions that will keep you awake, and training your brain that your bed is sleepy time, not entertainment time.

Studio apartment dwellers notwithstanding, your bedroom should be focused on sleep, and besides sex, sleeping is all you should do in there.

Next, make your bedroom dark, cool, quiet, and comfortable.

How dark is dark enough? As dark as you can get it. Any light in your room is bad (more on this below). This includes LED clocks, night lights, blinking lights on smoke alarms, and of course light coming through windows. Use blackout curtains and pull them tight, cover any exposed blinking lights with opaque tape, and if you need a clock, cover it with something so the light is extinguished.

The optimal temperature for sleep is around 65oF, provided you wear pajamas and sleep under covers. Obviously if you sleep naked without sheets, then the best temp will be a lot higher. Basically, you will sleep better in a cooler room than in a warmer one. Many people with insomnia appear to have problems cooling off when they sleep, and in some cases taking a cold shower before bed can improve sleep quality.

Quiet is a trickier concept. Some people are very sensitive to sound disturbances, others can sleep through anything. My father tells the anecdote of sleeping through the building next door literally exploding when he lived alone in an apartment (and still sleeps like the proverbial log), but my mother will awake if she hears a pin drop from across the house. Many people find that white noise is helpful, such as from a sound machine or a fan. Others find they need to use ear plugs. People from large cities often find traffic noise to be soothing. Find what works for you.

Finally comfort. First the bad news: Lucy and Ricky had it right with separate beds. When you sleep in the same bed as another person, you're 50% more likely to be disturbed in the night, and on average a person will achieve 30 minutes more deep sleep when sleeping alone versus with their partner. Romance aside, bigger beds mean better sleep.

As for mattresses, there is no such thing as a perfect one, no matter what the sleezy salesman will tell you. Find a mattress that you like, that's comfortable and in your price range, and go for it. No, you don't need an expensive mattress, and certainly not one that costs $150,000. In fact, a study in the 1960s demonstrated that people got the same quality of sleep whether they slept on a concrete floor or a mattress...granted, I bet there were some aches and pains upon waking up on the concrete, but the sleep itself was fine. Firm or soft, springy or sinky, coils or foam, just pick what you like in a reasonable price range. What's reasonable price-wise? The new direct-to-consumer mattress companies (Casper, Leesa, Tuft & Needle) provide a good gauge: they run ~$500-$1,000 depending on size.

Eat well and exercise

Shocker: better nutrition and increased physical activity are good for you!

I like to think about health as a three-legged stool, supported by the food you eat, the exercise you do, and the sleep you achieve. If any one of them is faulty, the stool doesn't sit right. While I plan a detailed review of nutrition and fitness in future posts, it probably is no surprise that each "leg" affects the other.

Briefly, there's early evidence that meals high in fat and carbohydrates can disrupt sleep. Consuming large amounts of carbohydrates (such as that from refined sources like bread, pasta, and sweets) can delay the body's release of melatonin, which we know from Part 1 is instrumental to the sleep-wake cycle. Additionally, your body uses both meal-timing and meal-size as zeitgebers, and when you deviate from your normal diet it throws off your body clock.

Just eat like your mom taught you: reasonable amounts of meats, fruits, and vegetables, and stay away from junk.

Exercise—in case you haven't heard—is like a miracle drug. Practically every aspect of your body can benefit from physical activity, and sleep is no exception. Animal experiments demonstrate that exercise can counter some of the negative effects of sleep deprivation, and we know from human studies that exercise can improve memory, enhance brain function, and prevent memory decline from aging. Furthermore, sleep quality is higher in adults that exercise regularly than those who are sedentary.

Beyond our scope here is how to exercise, but the fundamental tenets are:

Something is better than nothing
Do what you enjoy and thus will keep doing
More is better

However, exercising too close to bedtime (say, within a couple of hours) can make it difficult to settle down the nervous system before sleeping. If you must work out at night, make it a point to stretch and perform active release techniques with a foam roller or massage ball before going to bed, as it will help you relax.

Manage your exposure to light

As mentioned above, light is bad for sleep. In Part 1 we reviewed how light helps regulate your sleep cycle. Briefly, the part of your brain known as the suprachiasmatic nucleus (SCN) of the hypothalamus senses the presence or absence of intense light through your eyes, particularly in the blue color spectrum. When the amount of light is low, such as at night, the SCN prompts the pineal glad to make melatonin, which shuts down adrenaline production and prepares you to go to sleep.

Unfortunately, indoor light pollution is a serious problem (outdoors too). We keep our lamps blazing into the wee-hours, and entertain ourselves by staring at glowing screens, sometimes mere inches from our eyeballs. It is any wonder we have problems trying to fall asleep when your brain thinks you're going to bed when the sun is still up?

A meta-analysis of more than 125,000 children showed that, among those with access to a device at bedtime at least three times a week, there was an 88% chance of not getting enough sleep, a 53% chance of poor sleep, and they were twice as likely to be tired during the daytime. Another study showed that adults that used their back-lit mobile device (tablet or phone) within four hours before bed had their melatonin release delayed by more than an hour compared to controls that read normally (on paper) for the same amount of time. The delayed melatonin release made it take longer for the participants to fall asleep, they got less and lower quality sleep, and were less alert the next day. Unfortunately, the effects on delaying melatonin release were found to happen with only a few minutes of exposure to an electronic screen, particularly if it's held close to the face.

These toxic effects of light on your sleep are quite reversible. For example, camping outdoors for one week with the only light after dark from a campfire, was long enough to re-synchronize people to solar time, such that they went to bed at sunset and woke up just after sunrise...the natural pattern we discussed in Part 1.

Yet unless you go full-on primitive or become the weirdo on the block, you can't operate like that. So what can you realistically do?

Avoid glowing screens within an hour of bedtime.

First, do not look at a glowing screen of any kind (TV, iPad, phone, computer, etc.) within an hour before bed. Even a few moments exposure to that intense LED blue light is enough to disrupt your melatonin production.

If you absolutely have no choice and must look at a computer or phone close to bedtime, be sure you have installed or enabled color-shifting software. One the best known is f.lux for computers and some mobile devices. f.lux slowly turns down the amount of blue light coming from your computer screen, making it more orange. While this is better than normal, it's still not ideal: bear in mind that light intensity matters too, and holding a bright orange screen up to your face may not be much better than a dim blue screen from across the room (although I couldn't find any experiments testing that exact comparison).

On Apple mobile devices*, enable "Night Shift" mode, under display and brightness settings. Move the slider all the way to "More Warm." This will remove some (not all) of the blue light from the screen during the time you schedule it. Better yet is customization of the Color Tint manually with a special "secret" code. Do it like this:

Go to Settings, General, Accessibility, Display Accommodations
Under Color Filters, turn on by moving the slider to the right, and then slide intensity and hue all the way to the right. Your screen will get extremely red.
Next, go back to Settings, General, Accessibility and at the very bottom select Accessibility Shortcut, and choose Color Filters under the "Triple-Click The Home Button For:" selection
Now, test this out by triple-clicking the Home Button; you should be able to switch back-and-forth from extreme red to normal easily by triple-clicking.

If you use your iPhone as your bed-side clock and you look at it occasionally during the night, I urge you to set it in the extreme-red Color Tint mode before bed so you don't get a dose of blue light in the middle of the night and potentially disrupt your sleep.

Dimming the house lights before bed can also help. Some of the new, programmable LED light bulbs can even be tailored to change their color and increase warmth (decrease blue light) on a schedule, although it's cheaper to just turn off a few room lights.

Finally, getting real sunlight matters. While light indoors is relatively intense at night, it's actually rather weak compared to daylight. Daily exposure to sunlight of at least 30 minutes, particularly in the morning or over the lunch-hour, helps synchronize the body clock. Studies show that people who make this effort have higher quality sleep and less difficulty waking up the next day that those that do not. Even light through a window can help: people that work indoors next to windows have better sleep than those that do not work next to windows.

Have a routine

Your body loves ritual. Your hormones become entrained to how you live your life, and when you deviate from that schedule there are negative repercussions. For example: you get hungry around the same time every day, right? Your body is trained to expect food at the times you normally eat.

Sleep is the same way. Your body is trained to expect sleep at a certain time every day, and having the same (or nearly so) bedtime every night will help you ease into slumber. If you go to bed at different times, varying night to night, you're basically giving yourself jet lag. A good practice is going to bed within an hour or two of your normal bedtime, even if you don't have to wake up for your normal schedule the next day (weekends vs. weekdays).

Additionally, having a wind-down ritual at night can promote good sleep. Sleep disruptions and insomnia (more on this below) are frequently related to stress and anxiety. Hitting social media for a dose of FOMO, or checking your work email right before bed will keep your stress levels high and make it tougher to get rest.

Ways to unwind without electronics could include reading a book (an e-reader is fine if the back-light is turned off), playing a game with family, meditating, stretching...or any non-glowing-screen activity that will help your relax.

Avoid stimulants like caffeine and nicotine

The most widely consumed drug in the world is caffeine. More than 80% of adults in the USA drink coffee, a goodly portion of which probably feel like they can't survive without it. Besides coffee, caffeine is found in tea, cola, chocolate and many energy drinks. As discussed in Part 1, caffeine's stimulating effects are likely from blocking the action of adenosine on its receptors. The more adenosine you have in your brain, the sleepier you are. Therefore, caffeine will make you less sleepy.

Adenosine naturally builds up over the day and is one of the drivers of the sleep-wake cycle. If you ingest caffeine too late in the day, it could affect your ability to fall asleep and stay asleep. How late is too late? That will completely depend on the person. There is substantial variability between individuals on the metabolism of and reaction to caffeine. For some people caffeine may linger in the bloodstream for only a few hours, in others it may last more than a day!

The best rule of thumb is to avoid any caffeine after Noon. I'm hesitant to assert that quitting caffeine is ideal, both because my morning coffee is one of the deepest loves of my life (therefore, I am very biased), and because there is a substantial amount of evidence around coffee's benefits from judicious use: improves learning and memory, fights cognitive impairment from aging as well as neurodegnerative diseases like Alzheimer's and Parkinson's, and increases physical performance. [Related trivia: caffeine formerly was banned in the Olympics for its performance enhancing properties—now it's only monitored for abuse.]

On the other hand, I can unequivocally say that you should avoid nicotine. The primary delivery mechanism for nicotine is tobacco, the use of which has been linked to lung disease, cancer, diabetes, heart disease, reproductive issues, chronic inflammation, and much more. If you're still using tobacco, sleep is not your primary concern: tobacco is. Stop now. Get whatever help you need.

That said, what if you are a former tobacco user and you're still using nicotine patches to help with cravings? Experiments with healthy non-smokers have shown that a dose of nicotine patches before bed similar to that of one cigarette reduces sleep time and sleep quality. Therefore, if you're still using nicotine patches, avoid using them close to bedtime.

Avoid alcohol

If caffeine is the most widely used drug, alcohol is perhaps the most enjoyed. It's sad, then, that I have this news for you.

Experiments show that just one drink within two hours of going to sleep can disrupt your sleep, reducing sleep time and quality and increasing sleepiness the next day. This effect is dose-dependent:

The more you drink, the worse you sleep. [tweet this]

Why is it that so many people believe alcohol is a sedative and is useful as a night-cap or sleep aid? Because depending on the dose, the timing, and the vagaries of the user's metabolism, alcohol can have a sedative effect.

However, alcohol is an incredibly complex drug. Booze permeates our entire body when we drink it, affecting multiple physiological systems, most obviously our brain. Alcohol simultaneously relaxes you and makes you stressed.

Alcohol relaxes you by activating the GABA neural system. The GABA system is naturally activated in the evening, essentially slowing down the brain's neural activity, making you feel relaxed and ready to go to sleep. As long as alcohol is in the system, this sedative effect will be increased. At high-enough levels, GABA stimulation can cause black-outs and loss of memory.

At the same time, alcohol stimulates you by activating the sympathetic nervous system, the part of you that is activated when you're under threat or stress, the so-called "fight-or-flight response". When your fight-or-flight response is activated, your adrenaline goes up, your breathing increases, your heart rate increases, you sweat, your blood-pressure goes up, your pain sensitivity decreases, and ability to be sexually stimulated goes down. Basically your body is reacting like you bumped into a tiger in the woods and are preparing to GTFO--it's a fear response.

When you drink alcohol before bed, the sedation effect helps you "fall asleep". The alcohol partially knocks you out. While you're under, REM sleep is inhibited, and your fight-or-flight response is kicking in, but you can't sense it. Then, in the middle of the night, the alcohol finally wears off and the sedation effect goes away. At that point your brain can't ignore the sympathetic nervous system response anymore, and your sleep is disturbed, so much so that you may even wake up with a racing heart, drenched in sweat. This is such a well known phenomenon that ER docs have a nickname for it: "Holiday Heart Disease." People drink a lot over the holidays and end up waking in the middle of the night thinking they are having a heart-attack, and go the ER!

Unfortunately, it appears that the fight-or-flight stimulating effects of alcohol outlast the sedating effects. Even if you're completely sober by the time you go to bed, alcohol you had earlier in the day can still negatively affect your nervous system while you sleep.

The point is that while alcohol can help you go unconscious, it only hurts your overall sleep. If you use alcohol, avoiding it will improve your sleep.

Use sleep devices judiciously

Recently there's been an explosion of gadgets that purport to help your sleep. Sleep trackers, apps, smart clocks, smart beds, smart pillows, even smart PJs! I've tried a bunch of different sleep gadgets and tools, but they come out with new ones so fast it's hard to keep up.

Two two gadgets I'm currently very happy with are the Philips Wake Up Light and the Eight Sleep Tracker smart mattress pad.

There are a lot of smart alarms out there, but the Philips Wake Up Light gently makes it gradually lighter in the room, similar to a sunrise, creating a less abrupt way to wake up. Unlike an alarm that you set for a specific time, the Wake Up Light is set for a period of time with a deadline so an alarm goes off eventually if you don't get up. Therefore, some days I wake up a little earlier than I need to, but I feel refreshed anyway because of the nature of the soft-glow light. Many trackers offer a smart alarm that does something similar, where the tracker uses an algorithm to wake you up when you are tossing or turning, which they take as an indication of lighter sleep and an ideal time to wake up. However, I find that they still feel like an alarm, and I hate alarms. The Wake Up Light reminds me of what it feels like to wake up on a weekend without an alarm clock...of course not exactly.

The Eight Sleep Tracker smart mattress pad also offers a smart alarm (although I don't use it). Like other trackers, it monitors when you go to bed, when you get up, and how restless you are while sleeping. The Eight also monitors room and bed temperature, and tracks your respiratory rate. The accompanying app gives you a sleep score each morning so you can get an idea of your sleep quality. But the best feature is Eight's ability to warm the bed according to a schedule, and to differentiate sides if you sleep with a partner. In the morning, my wife and I compare who slept better and the winner gets to humblebrag.

However, it's important to point out that consumer sleep trackers are notoriously inaccurate. Many track (by various means) your movement, and equate minimal movement to good sleep. However, a night involving alcohol consumption may cause you to be less restless. That may cause the tracker to say you slept "better," but in fact your sleep quality was much worse. Make sure you consider the limitations. Accurate sleep tracking looks like this:

Counter-intuitively, there's some thought by the experts that sleep devices may actually be making sleep worse for some. How? By making you neurotic about it, and anxiety is a key factor in insomnia and poor sleep. That said, if you approach sleep gadgets with a good attitude, it can be a fun process to find some that are useful and make your sleep experience (sleeperience?) more enjoyable.

~~~

Sleep Therapy

Where hygiene is efforts to promote health, therapy is what you do to fix problems. We all have poor sleep occasionally, some more than others. What can we do about it when it happens?

Is it okay to take naps?

I've always been a bit surprised that napping is controversial. Naps have restorative effects, counteract some detriments from sleep deprivation, and can improve cognition. Study of indigenous populations as well as non-human primates shows that napping is widely practiced and a natural part of our circadian rhythm.

Controlled studies back this up. Following a night of sleep deprivation, a nap helped prevent some of the expected negative hormonal and immune affects, as well as increased alertness and cognitive performance. One study even demonstrated that naps are better than caffeine for an afternoon pick-me-up. NASA studied 747 pilots back in the 90s, and found that when pilots were permitted to nap for 40 minutes, they averaged 26 minutes of sleep, and had 16% better reaction time and 34% less lapses compared to pilots that didn't nap. And a study in Greece showed that men who took an afternoon nap at least three times a week were 37% less likely to die from a heart attack.

So if you have a bad night of sleep (smoke alarm beeped, kid got sick, late flight home, etc.), a nap in the middle of the day may be just what you need. But how long should it be?

This is perhaps where some negative effects could come into play. The longer a nap, the more likely it is to disrupt your natural sleep cycle. I wouldn't recommend crawling into bed and sleeping for a couple of hours in the middle of the afternoon, as that is sure to mess up your natural sleep pattern.

Most experts suggest a nap of 10-30 minutes is just about right. Longer than that may results in grogginess, although some studies suggest that a 30-60 minute nap improves creativity and learning better than shorter naps. Shorter naps appear to be best to improve alertness and cognition.

For a quick boost, its hard to beat a drop nap. You simply get in a position that comfortable for you while holding something that safe to drop (hence the name), such as a book, magazine, pen, etc. As you relax and slowly drift off, when you begin to fall asleep your muscles will relax and you'll drop whatever you were holding, which will bring you around. In my experience this is basically the same thing as a power nap, and lasts about 10 minutes.

Alternatively, you simply set an alarm for desired period...but like I said above, I hate alarms.

What to do if you sleep bad regularly or all the time?

Here's where I remind you that nothing provided here or anywhere on this website is medical advice. You should always talk to your health provider about medical issues, including sleep problems.

If you regularly encounter sleep problems, you're not alone. Population studies suggest that half of the USA experiences mild or severe insomnia, and a solid portion of the rest experience regular sleep disturbance. In other words, a majority of us experience unfulfilling sleep. We discussed in Part 2 that the majority of us are sleep deprived, and it would seem that we also don't want that to be the case. Our collective sleep problem is so bad that it has even led to the rise of a mini-industry of audio podcasts so boring that they help you doze off.

The National Science Foundation estimates that 25% of the population use sleep drugs every night...not including alcohol. Considering the incidence of alcohol abuse is more than twice as high in those with insomnia, it's probably safe to say that most of us use something to help us fall asleep.

Unfortunately, there aren't any drugs that can safely and effectively treat persistent sleep problems. We've already discussed alcohol above, and nobody would say that chronic use of alcohol for sleeping (which would verge on abuse) is healthy or safe.

Prescription sleep drugs are also fraught with problems. By and large they are addictive and have significant negative side effects, including sleep-walking, sleep-eating, even sleep-driving! Essentially you might do crazy things while "asleep" that you normally wouldn't do, and have no memory about it (in other words, amnesia). Not to mention the risk of overdose, which has occurred with multiple celebrities.

But the real kicker is that in controlled trials, sleep drugs only increase total sleep time by about 10 minutes. It would seem that they have a bigger effect of a person's perception of sleep, more than the sleep itself. That is, if you take a sleep drug you're apt to feel like you slept better whether you did or not, and studies have demonstrated that when people believe they slept well, they show improved cognitive performance the next day, compared to those that believe they slept poorly, regardless of how well they actually slept. That's the placebo effect in action.

If you and your physician choose to use prescription sleep aids, use them with caution.

What about supplements? There are a number of "natural" supplements marketed for sleep, such as melatonin, valerian, 5-HTP, GABA, hopp extract, L-tryptophan, vitamin D, magnesium, and on and on. Any supplement you put in your mouth is effectively a drug. You are ingesting a pure (hopefully...supplement manufactures are not beholden to the quality requirements of pharmaceutical companies) substance to cause a physiological effect. That's a drug. In fact, melatonin is only available as a prescription in many countries, and was recently approved in a time-release formulation as a prescription drug by the FDA. The point here is that some sleep supplements could be effective (reports in the scientific literature are quite mixed), but you should not experiment with them on your own. Talk to your physician.

So if prescription sleep drugs are mostly placebo, and supplements are a questionable and suspicious collection, what works?

Provided the insomnia is primary (not secondary to a condition that is keeping you awake, such as chronic pain), then the best treatment in the literature is Cognitive Behavioral Therapy (CBT). CBT is a psychotherapeutic approach where a certified therapist (typically a psychologist) assists the client in finding and practicing effective strategies to address the identified goals and decrease symptoms of the issues.

CBT is used to treat a number of conditions (depression, stress, anxiety, etc.), and has proven to be more effective than drugs for insomnia—about two-thirds of people who have CBT don't need sleep medication after a few months. Common CBT approaches used for insomnia include reinforcing the association of the bedroom with sleep, keeping a consistent sleep schedule, relaxation training, and practices that reduce anxiety about sleep and re-frame unhelpful beliefs about insomnia. Receiving CBT from a therapist is like coaching for relaxation and good sleep hygiene, as well as identifying and correcting the underlying cognitive issues that keep you from achieving good sleep.

If you're afflicted with primary insomnia, and you'd like to try CBT, you should find a certified psychologist. If you are in the USA, every state has a psychology organization which you can contact and find psychologists in your area that practice CBT.