I have previously confessed on the pages of this blog that of the four pillars of health and wellbeing, sleep is the one that I need to work on the most. I have suffered from Sleep-Is-For-Wimps machismo and been convinced that I could get much more done in life and generally enjoy myself more if I can just sleep less. I have always proudly considered myself an owl rather than a lark, or even both an owl and a lark at times. I have (sort of) gotten away with it because I probably do need a little less sleep than the average person and so have pushed it and given myself even less. I often get sleepy during day, particularly in CCG board meetings and church sermons!
As I have developed my knowledge and understanding of wellbeing, however, I have really felt challenged in this area. Reading the excellent Four Pillar Plan, the fascinating Why We Sleep and listening to podcasts on the topic has made me realise I needed to address this area for personal and professional reasons. What put the tin lid on it, however, was the results of analysing my personal health data and looking at the effects of sleep (or lack thereof) on my recovery. My friend and colleague Simon Shepard is the chief executive of a company called Optima-Life. He offered to fit me with a device that measures something called R-R interval variation. I won’t go into all the science for the purpose of this blog post today but essentially wearing this device for three days resulted in a lot of data being generated which could then be meaningfully interpreted to look at the implications for my health and performance, and where the areas for improvement are. I decided to use myself as a guinea pig for the three days and nights I wore it. For the first night I did not drink alcohol and went to bed at a sensible time. For the next night, I had some alcohol, went to bed later and spent some time on my phone before going to sleep. For the final night, I was away on a weekend with friends and stayed up late and drank more alcohol (all in the interests of science, you understand!)…followed the next day by reasonably intense physical activity which included mountain biking and a water park. After the data had been analysed, we sat down together and Simon went through it with me very carefully (and non-judgementally!) explaining the results, which were really eye opening. My body’s “recovery” over the first night was good with excellent quality sleep. Without boring you with the details, it all went downhill from there. Nice big green bars of sleep and recovery became little angry red ones and frankly I’m amazed I made it back home from the weekend alive! It left me asking some big questions about what I wanted for myself from both a personal and professional perspective.
Why should we be bothered about sleep?
Sleep is freely available to all of us regardless of our means and circumstances. It may turn out to be the bedrock of our health. There is increasingly compelling evidence both of the benefits of good sleep, and the links between sleep deprivation and health conditions including heart disease, cancer and dementia. There must be a pretty good evolutionary reason that we spend about a third of our lives in an apparently comatose, vulnerable state. The evidence is not clear why the amounts and type of sleep varies between organisms but there is speculation that neurological complexity could be part of the picture, along with many other factors that we are only just beginning to learn about. Going to work sleep-deprived has similar effects cognitively and physically to being hung over or even drunk. The general medical council would clearly have something to say about my doing the latter…so why shouldn’t I take sleep as seriously? If you really want to learn more, I recommend reading Why We Sleep by Professor Matthew Walker.
So, feeling inspired by all this evidence based medicine, I thought I would apply these principles to myself and report back with my personal, anecdote based medicine outcomes.
The practical steps that I took to improve my sleep
- Setting a bed time. By intentionally choosing a specific time that I wanted to be in bed, lights off, head on the pillow, I was setting a goal for myself which others also knew about and so could hold me accountable for. This was a different approach to my traditional open ended “I’ll go to sleep whenever I feel like it” approach, often extended even further by phone checking etc. I decided I wanted to be going to sleep around midnight. For me, this means going up to bed around 1000-1030 to allow for getting ready for bed and winding down. I didn’t achieve this every day, but even achieving it most days was a big improvement.
- Not using a mobile device (phone, laptop, kindle, iPad etc) for the last hour before bed. Whilst I feel that I have always got to sleep quickly once my head hits the pillow, I now know from my optima-life data that using a screen before bed reduces the quality if not the quantity of my sleep. This was one of my biggest struggles as I had a habit of doing it. So I asked myself what it was that I was using the phone for (checking social media, reading the BBC football pages for Manchester United transfer gossip etc) and whether it really needed doing just before I was going to go to sleep or whether it could wait until tomorrow. Of course it didn’t need doing. I was not going to wake up the next day less well informed or happy as a result. Some people strongly advocate not having phones in the bedroom if it is too big a temptation. You can always buy yourself a good old fashioned alarm clock.
- Reducing blue light. As the sun sets and it gets darker, our bodies naturally produce melatonin which is the starting point for a good night’s sleep. The levels continue to rise into the early hours of the morning and then decrease as dawn approaches and it gets lighter. Exposing ourselves to light, particularly blue light from screens, sends a conflicting message to our brains and interferes with melatonin production. I turned on the nightlight settings on iPhone and MacBook screens, from 9pm to 7am. I don’t know whether it’s partly psychological, but looking at a screen that is dimmer with a warmer tint and the blue light reduced feels very different to me. You can download filters for phones from the usual app stores, or even physically apply a screen filter your phone that does the same thing.
- Making the bedroom a room for sleeping. One of the problems with our modern life is that people’s bedrooms can easily also become dining rooms, living rooms and offices. Disciplining yourself and making your bedroom a place reserved for rest and relaxation sends a message to your brain when you go there that now is the time for sleep. I try not to use the bedroom during the day if I can avoid it, particularly not for work. The laptop tray that I bought a while ago so that I could sit up late at night typing away now lies (mostly) unused by the side of the bed.
- Reading before bed. This helps me relax. I now do it instead of staring at a screen. As well as sleeping better, it means I am enjoying reading the books I have been meaning to for ages. Although I have noticed that I can usually manage about five pages or less before my eyes start to nod…a signal that I now listen to instead of trying to ignore!
- Using ambient or white noise. Dropping off to sleep is not a problem for me, generally speaking. However, I have both friends and patients for whom this is an issue. One thing that can help is the generation of quiet background noise. The easiest way to do this is using a phone app. Whether you like the sounds of the rainforest, falling rain or breaking waves, there is something for everyone out there. I personally use the Reflection app designed by Brian Eno. It’s an ambient music generator which means that you never listen to the same soundtrack twice. Very cool. Of course, if you have banned phones from the bedroom you can always use a bluetooth or airplay speaker so that your phone doesn’t have to be in the same room.
- Avoiding exercise in the evening. It’s already well established that this is likely to interfere with sleep. If I’m going to be exercising, I will get it done during the day.
- Reducing use of alcohol. I had already read about the effects of alcohol and listened to parts one and two of the Feel Better Live More podcast conversation between Dr Rangan Chatterjee and Professor Matt Walker but if I needed any convincing then Simon’s visual demonstration of the effects alcohol consumption had on my recovery during sleep (and the next day) did it nicely. I know that for many of us, enjoying a glass of wine or beer in the evening is part of winding down. I’m not going to be pious and preach about bad habits or the alcohol consumption of the middle classes. I just take this into account when planning my evening and socialising. I might have a drink earlier rather than later, or not at all. I might have one rather than two. If I’m planning a night out with friends and enjoying a few beers, I won’t let that stop me. I just need to acknowledge what the likely effect is to be the next day, and ideally not to combine it with the perfect storm of alcohol consumption and a very late night, or at least bear in mind that if I do, sympathy from my family and colleagues will be in short supply!
So what did I achieve as a result of this new approach to my sleep? Below is a screenshot from my fitbit, which has a sleep monitoring function. The figures are crude, but it gives you the overall idea.
As you can see, my weekly average sleep was consistently poor beforehand, with figures from February closely tallying with figures from the last week before I made the changes. Last week’s figures are significantly different, with my weekly average going up by almost an hour and a half a night, from 5 hrs 24 mins to 6 hours 47 minutes.
Now I know what you’re thinking – numbers are all well and good, but what did this mean? What was the end result for my wellbeing? Well, since you asked…
- I now wake up before my alarm most mornings.
- I now wake up feeling more refreshed and ready to go.
- I have created more time in my day to be genuinely productive e.g. getting admin completed before work (rather than falling asleep over it in front of my laptop the night before, having read the same paragraph at least five times), being able to start the day with a short walk or some brief meditation, or just feeling less hurried as I start the day with time to spare.
- Less day time sleepiness. Whilst it is natural for most of us to go through a bit of a dip in the early to mid afternoon, I struggled with this particularly if I was sitting in a meeting or doing some work in front of the computer. I have noticed a definite improvement in this area. I would of course like to issue a disclaimer that I still reserve the right to rest my eyelids temporarily if in a particularly dull meeting.
- I feel I’m practising what I preach. This is important to me. As a doctor I need to be credible. Discussing lifestyle medicine with a patient when I can barely keep my eyes open is not really any different from sitting there with an enormous beer belly whilst smoking a fag and opening a can of super strength lager…not internally, anyway.
In the interests of full warts-and-all disclosure, I have noticed a downside to getting more sleep. Now that I am waking up and getting up earlier, if I crash around too much I wake up my wife. I’m not sure what you call someone who is neither an owl nor a lark and would like 8 hours or more a night. Grumpy, possibly.
That’s it for this week. I hope that this has been helpful for you, whether you want to sleep better yourself or want to be able to help others. The weekly wellbeing round up will be back next week. In the meantime, take care of yourself.
Dr Richard Pile