Sleep and Longevity

Aric: When people don't get the sleep they need, life is just harder, right? Every little thing is just more of a struggle—the slings and arrows of the day are just a little bit more painful.

BrentWelcome to Death Clock. I'm your host, Brent Franson. Today we speak with Doctor Aric Prather about stress and sleep. Doctor Prather is the author of The Sleep Prescription: Seven Days to Unlocking Your Best Rest. He's a professor at UCSF, a psychologist, and a researcher. We get into all things stress, sleep, and insomnia, and we talk about wearables like the Oura Ring and the Eight Sleep.

BrentHe's a wonderful resource on how we can think about our sleep and the relationship between stress and sleep. Hope you enjoy.

BrentDoctor Aric Prather, welcome to the show.

Aric: It's so good to be here.

BrentWe're going to talk about longevity as related to sleep and stress today. This is near and dear to my heart. I've struggled with sleep for a long time, but I actually slept pretty well last night, which is rare for me. So I'm feeling really good today, but I'm guessing that I'm not going to like a lot of what you have to say.

BrentMy mom says, "I'd rather be hurt by the truth than happy with a lie." But before we get in, will you just give us a sense of your background and bio?

Aric: Yeah, absolutely. So I'm a professor here in the Department of Psychiatry and Behavioral Sciences at the University of California, San Francisco. I'm a licensed clinical psychologist. I help run a sleep clinic here focused on treating insomnia primarily with a non-pharmacologic treatment called cognitive behavioral therapy for insomnia (CBT-I). But I also run a research program with several colleagues here at UCSF focused on understanding what happens to our bodies when we are under stress or don't get enough sleep,

Aric: primarily focused on the immune system and aging biology in humans.

BrentWhat got you into sleep and stress? What was the motivation?

Aric: I was really interested in stress, and what brought me to it was my interest in the immune system. It's incredibly complicated, but so essential. I thought I was going to go to medical school, and I was working with a psychiatrist doing research and just fell in love with it. We were doing work on depression and neuroendocrine hormones.

Aric: I ended up getting into graduate school at the University of Pittsburgh, where they were building an immunology laboratory in the Department of Psychology, which is very uncommon. I was hooked. I was doing work bringing people into the lab, stressing them out, drawing their blood, and seeing what happens in the wet lab space.

Aric: During that time, I kept hearing about their sleep problems. We added a bunch of measures for people's sleep in the projects we were doing. When I started looking more into it, a lot of the things that happen to our immune system and health under chronic stress or acute perturbations of stress,

Aric: you also see when people undergo sleep loss. It's not surprising that it's bidirectional. But oftentimes researchers in this space focus on one or the other—either your daytime experience or what happens when you close your eyes. I thought that was a shame.

Aric: My goal has really been to marry the two, because in our lived experience, they are obviously interrelated.

BrentLet's start with stress. How do you define stress, and can you give us the distinction between stress and anxiety?

Aric: As stress researchers, we focus on both the outside stressful life event—that thing that happens—and your psychological experience of it, as well as the physiological consequences of those things. Stress is one of those challenging words we use a lot,

Aric: but we often don't define, so it becomes less particularly useful in a scientific sense. Generally, things considered stressful are uncontrollable, things where we don't necessarily have the coping mechanisms to deal with them, and high demand.

Aric: Some of the most powerful types of stressors are high demand where you have low control, and those seem to have a negative impact on health. Psychologically, stress refers to things that increase negative affect or emotion and set off a cascade of physiological responses that over time might be harmful to health, though in the short term they are adaptive to get us into a fight-or-flight state.

Aric: Stress is often something that happens to us and our response to it. Anxiety is almost like a mindset related to worries about the future or past. It's certainly adjacent to stress and can be upregulated under stressful experiences, but it can also be dispositional in how we construct meaning from what happens to us, impacting our thoughts, behaviors, and

Aric: opportunities for psychological therapies.

BrentWe all have some genetic predisposition for stress tolerance, and some of us are probably better at handling stress than others. It seems the way I respond to stress is what matters. If two people are in a really stressful situation, say in a foxhole at war,

Brentone person might respond in a healthier way than the other. Even in an identical situation, the response to stress is what matters for physiological consequences, right? It's not the stressful situation itself, but how we respond.

BrentAnd that differs from person to person.

Aric: In that specific example—which isn't how we usually experience the world, thankfully—there are dispositional differences, personality factors, and lived experiences. There's this idea around stress inoculation where prior exposure builds up resilience for the next time.

Aric: There are social support and environmental factors that provide psychological resources during a stressful life event. Additionally, structural factors contribute to the types of stressors people experience.

Aric: Even looking at an individual in a unique stressor, historical factors and prior exposures feed into that moment.

Aric: Personality, dispositional factors, and individual differences drive how people respond and influence long-term outcomes related to stress.

BrentTo draw a simpler example: if two people are sitting in traffic and late for an important meeting, the traffic itself doesn't directly cause issues with their immune system or sleep.

BrentIt's the way they respond to it. Temperament, past experience, and learned coping mechanisms shape that response. So it's the response causing the problem, not the stressor itself.

Aric: It's a transactional model involving exposure combined with what you bring to it—temperament, past experience, self-efficacy, or coping abilities—which modulates the downstream impact. Absolutely.

Aric: Absolutely.

BrentWhat are the downstream impacts for someone regularly dealing with high stress and responding to it in a typical way?

Aric: We can think about it in terms of emotions—experiencing anger, anxiety, depression, or general negative affect. Behaviors also play a role when people engage in coping mechanisms like substance use, eating comfort foods, or smoking to downregulate the stress experience.

Aric: Then there are biological outcomes: activation of the hypothalamic-pituitary-adrenal (HPA) axis, output of cortisol, and increased sympathetic nervous system activity (adrenaline and noradrenaline). Downstream effects impact the immune system.

Aric: Under acute and chronic stress, we regularly see an upregulation in inflammatory activity—specifically pro-inflammatory cytokines. High systemic levels of these cytokines contribute to many age-related chronic conditions common among people experiencing chronic stress.

Aric: So one of the things that we see, you know, regularly in, in kind of the literature around, say, acute and chronic stress, is this upregulation in inflammatory activity. So pro-inflammatory cytokines that are critical for communication without the within the immune system, but actually at high systemic systemic levels are kind of well known to contribute to many of the Aids related chronic conditions that we see at increased risk rates among people who are experiencing things like chronic stress.

BrentWhat do we see regarding specific outcomes like lifespan, probability of chronic disease, or other markers?

Aric: Over time, stress increases the risk for cardiovascular disease (such as atherosclerosis and plaque deposition), cardiometabolic conditions like type 2 diabetes, and weight gain.

Aric: Obesity and weight drive many age-related chronic conditions that ultimately decrease lifespan or healthspan. Our lab focuses heavily on markers of biological aging, researching the impact of stress on telomere length, geroscience outcomes, and mitochondrial dysfunction.

Aric: All these individual biomarkers play a clear role in pathways toward negative physical health outcomes.

BrentHow much of this is a direct physiological response to stress versus secondary effects, like self-medicating or lifestyle changes? When I'm stressed out, I'm less likely to exercise or sleep well. Do we know how causal the direct stress response is versus that constellation of secondary factors?

BrentI just I'm less likely to work out. I'm less likely to sleep well. So that would be in the kind of secondary effects I'd do. We feel like we have a good sense of, okay, these health outcomes are not good. How causal is it or how correlative is it directly to stress response versus the constellation of things that happen outside of the direct stress response?

Aric: The bulk of literature supporting the relationship between stress and health outcomes focuses on people dealing with chronic, toxic stressors over long periods, making it challenging to prove a strict causal path with available observational data.

Aric: We don't randomize people to chronic stressors. However, observational data during acute events show clear impacts. Studies following World Cup matches or 9/11 showed noticeable upticks in emergency room visits, heart attacks, and cardiac defibrillation events.

Aric: Acute stress presents a clearer causal path. But as you noted with traffic, we can't always change the stressor, so managing our response and pathways is key.

Aric: Health behaviors might seem like the less exciting factor, but they likely have the biggest impact. That's why I focus heavily on sleep—we know concrete ways to help people sleep better.

Aric: The world is stressful, so I focus on what I can control: exercise, nutrition, cutting back on harmful habits, and prioritizing sleep by putting the right tools in place.

BrentWhat is the relationship between stress and bad sleep?

Aric: Insomnia research is predicated on the idea that something precipitates it—a stressor or event disrupts sleep and gets the brain spinning.

Aric: It is initially adaptive to have difficulty sleeping under stress because you may need to stay alert and take action.

Aric: Over time, even after the stressor abates, people continue having sleep problems because short-term choices undermine how natural sleep works. There's a strong relationship between stressful events—especially near bedtime—and sleep disruption.

Aric: Most people with acute insomnia can identify the trigger. Patients in my clinic with decade-long insomnia often don't remember the initial event, but the pattern remains.

Aric: We've done longitudinal studies using research-grade wrist devices for three weeks alongside daily diaries tracking morning mood, daily stressors, and coping responses.

Aric: To disentangle subjective feelings from objective stressors, independent coders rated the severity of reported events using a standardized scale.

Aric: We also people report kind of what is the most stressful thing that happened to them. And then we have kind of separate trained coders kind of judge the severity of that. So it's not like you say, you know, no traffic is the worst thing that happens to me. This is so terrible. We actually have people. We have like a dictionary of like, well, for the more money, you know, the average person, it's like, you know, it's stress of three.

When looking at both directions, daytime stress rarely impacts objective sleep length or disruption unless the stressor is severe or right before bedtime. It affects subjective sleep quality and perception, but not necessarily total sleep time.
Aric
So we can kind of disentangle that and what we find when we look at kind of both directions of sleep, predicting stress and stress, predicting sleep, we actually don't find unless the stressor is incredibly severe or it's very close to their bedtime, that it plays a huge role in someone's sleep. It impacts their sleep quality, their their kind of affective experience of their sleep.

Aric: Conversely, sleep strongly predicts daytime stress. Replicated across multiple labs, getting less sleep than usual leads people to report significantly higher stress the next day.

Aric: They select into more severe stressors, react more intensely to negative events, and feel the day's challenges more acutely. Without sufficient sleep, everything is just harder.

Aric: That daytime strain feeds back into the night, creating a compounding cycle of wear and tear on health.

Aric: The main exception is for ruminators—people who tend to get stuck in their heads about an event. That active cognitive processing directly impairs the ability to wind down and sleep.

BrentThat's surprising and refreshing to hear—that poor sleep contributes to stress more than stress hurts objective sleep. The finding that stress affects subjective perception of sleep quality without showing up on wearables is fascinating.

BrentThere's a compounding effect there. And then it seems that can that can spin out of control a little bit. And then the second thing that you said was, the stress might hurt the their subjective interpretation of the quality of their sleep. But actually in the wearables, you don't see that it hurts the sleep. And so what's the difference to the person?

BrentWhy do you think that disconnect occurs, and what is the knock-on effect of incorrectly judging your sleep quality?

Aric: It's a fascinating problem. Part of it stems from personal expectations of what sleep should feel like.

Aric: In the clinic, patients working on insomnia will often judge reasonable nights harshly because they anchor on rare, perfect nights where they slept completely motionless and woke up feeling extraordinary.

Aric: When that rare outlier becomes the benchmark for success, typical healthy sleep gets rated as poor quality.

Aric: Additionally, daily affect plays a role—people feeling low or depressed are less likely to report positive experiences generally.

Aric: There may also be subtle elements of sleep architecture that standard measures miss.

Aric: Even consumer devices like the Oura Ring provide nightly averages rather than micro-level structures. Patients frequently report waking up early in the morning under stress, but catching one final hour of deep dream state that transforms their whole day.

Aric: Standard polysomnography rarely isolates those specific morning windows, yet subjectively they feel impactful.

Aric: It highlights how much we still have to learn about sleep quality and daytime mood function.

Aric: How you feel during the day is what matters most in living. Understanding the discordance between subjective ratings and wearable metrics remains an active area of investigation.

Aric: Right. And so, you know, trying to trying to figure it out and and but it but it is a, it is a conundrum. This kind of discordance between someone's quality rating and kind of what what we see on these wearable devices, which are thought to be more kind of objective measures of of what sleep is.

BrentWhat tools do you recommend? For instance, do you use an Oura Ring? What benchmark metric signifies a good night's sleep objectively?

BrentMaybe that's an oversimplification. So what is what tool do you like? Like, let's be specific. Like, are you you're the consumer. Are you like, hey, the aura ring. And what are you looking for when you say based on these objective measures, you consider it a good night's sleep? Like, I don't know how we would define good, but not excellent and not bad.

BrentHow many hours or what sleep score should we aim for to think about sleep objectively?

Aric: I work collaboratively with Oura in research (though I am not paid by them). Consumer device algorithms are proprietary black boxes, so there isn't one universal score. However, organizations like the American Academy of Sleep Medicine recommend at least seven hours of sleep for optimal adult health.

Aric: That is a baseline recommendation, not a one-size-fits-all rule. We encourage people to reflect on how much sleep they need when low-stress, unconstrained, or away on vacation to feel fully functional.

Aric: Usually, that sweet spot falls between 7 and 9 hours, though occasionally individuals function well on 6 or need up to 10.

Aric: Like if you had to cut out caffeine, and you didn't use kind of substances that affected your sleep. Like what? What would that be that you think would be the metric that we shoot for? And usually it is somewhere like in the 7 to 9 range. Right. Like once in a while we get people that are in the six.

Aric: Some people it's sometimes it's ten.

BrentTo clarify, when we say 7 to 9 hours, do we mean actual asleep time—meaning 8 hours spent in bed—or total time in bed?

Aric: We mean actual total sleep duration. Large population studies historically relied on single-item survey questions, but controlled studies using wrist actigraphy affirm that actual sleep time under six or seven hours correlates with marked health vulnerabilities.

Aric: But it was like, how much sleep do you get in 24 hours? You know, and it brings up the same question, like we were probably like, well, do they mean how much time in bed I spend or how much sleep? I'm like, we don't know. Like, but all there's, all we have, right, is the data we have. We think it's amount of sleep.

Aric: In one study where we exposed participants to rhinovirus, people sleeping less than six hours were significantly more likely to develop a clinical cold compared to those getting over seven hours.

Aric: Consistency of timing also predicts health outcomes independent of total duration. Maintaining consistent bedtimes and wake times is fundamental.

Aric: When treating insomnia, the first step is stabilizing the morning wake time to entrain the circadian rhythm.

Aric: Waking up at the same time daily helps stabilize sleepiness onset in the evening, relying on the body's homeostatic sleep drive.

Aric: Avoiding daytime naps allows homeostatic pressure to build and peak by bedtime, making it easier to fall asleep.

Aric: About 20% of the night consists of deep slow-wave sleep, mostly in the first half, followed by REM sleep. While all stages are essential, maintaining total duration and schedule consistency remains the best clinical tool we have.

Aric: And then, you know, there's a portion that's the REM sleep that's dreamy. All of those pieces of sleep are important, but we don't at this point in human history, do not have a lot of tools to kind of mess around with that stuff. But, you know, collectively, those things should put people in a place where they do feel like they are getting good quality sleep as long as they don't have, you know, other things that get in the way, like pain or disease, common comorbidity or sleep disorder or something like that.

BrentI've noticed I have a personal sleep window around 9:00 to 10:00 PM. If I stay up late, I sleep much worse despite feeling tired. Since I have young kids, my wake time is fixed regardless.

BrentI normally am in bed a couple hours before this, but I slept really poorly. And I've got young kids, so I'm always up at the same time, no matter what. There's no like sleeping in.

Aric: Human alarm.

BrentParents see this with children too—missing their bedtime window leads to worse sleep quality rather than extra sleep. Is this phenomenon supported by objective science?

BrentIt'll actually be a harder night of sleep if you miss the time that they're going to sleep. So is that a part of it? Is that is that my subjective? Is that my subjective misinterpretation or we're seeing we're seeing the same thing in the objective science?

Aric: There isn't extensive formal literature validating a strict "sleep window" concept, but behavioral cues play a key role. Pushing past regular sleepiness requires stimulating behaviors that make winding down harder.

Aric: Additionally, fixed morning wake times truncate overall sleep duration, leading to poorer recovery.

Aric: Consistency in evening rituals trains the brain to predict sleep onset. When those routines are disrupted, sleep efficiency drops.

Aric: But in general, those things are kind of conserved and help our brains kind of make important predictions about what's going to happen next. And, you know, and I think when those are perturbed, when we don't follow those patterns in quite the same way, there may be kind of implications for our sleep and kind of our well-being in general.

Aric: It's similar to mild jet lag: circadian misalignments complicate sleep onset despite high fatigue levels.

BrentWe know basics like keeping the bedroom dark and cool, putting screens away, avoiding late caffeine and alcohol. But what about meal timing and nutrition, such as intermittent fasting or early dinners?

BrentLet's not, like, lay in bed and look at the phone and okay, alcohol is not going to help the sleep or caffeine late in the day. Some of you disagree with those. I'm assuming you're like you agree with all of them, but I think one of the the thing we've been talking about more is when you eat and what you eat, you know, there's this guy running around saying, needs dinner at 11 a.m. because that's how he gets a perfect sleep score.

BrentAs an insomnia specialist, what is your view on how what and when you eat affects sleep?

Aric: Chrononutrition is a growing field. While reviewing NIH grant proposals, I noticed a strong surge in compelling research in this area.

Aric: Eating heavy meals close to bedtime causes GERD or indigestion, interfering with falling and staying asleep.

Aric: Dr. Marie-Pierre St-Onge at Columbia wrote a great book called Eat Better, Sleep Better exploring these relationships.

Aric: That's going to make it hard for people to sleep. I think there are like a really, really interesting field of like, Chrono Nutrition. You know, where, you know, maybe about the things that you eat. There's a, a book that just came out by Marie Pierre Saint on she's at Columbia, wrote a book called like Eat Better Sleep Better.

Aric: While some claims online cross into pseudoscience, specific dietary timing and composition (like complex carbohydrates) do show promise.

Aric: However, as a sleep researcher focused on homeostatic drive rather than strictly circadian biology, I place primary emphasis on homeostatic sleep drive over nutritional adjustments when treating patients.

Aric: And, and that may be less affected by nutritional factors and more of kind of like an endogenous drive and need for sleep that we try to leverage clinically.

BrentAnecdotally, lighter and earlier dinners seem to help me. Heavy meals late in the evening disrupt my rest. Yet in Europe, people drink espresso and alcohol late into the night and seem to sleep fine.

BrentBut then I think of, you know, so we go to Europe every summer. When we're in Europe, we like, we have wine every night and these late dinners and these Europeans, they'll have espresso at like 11 p.m., like right before bed. And I think I always blame alcohol. My alcohol really ruins my sleep. And so I don't drink very much.

BrentWhen traveling in Europe, relaxed stress levels seem to outweigh alcohol or caffeine intake. How do we account for people who break typical rules due to genetics or lifestyle?

Aric: Genetic variations in caffeine metabolism exist within populations. Cultural habits adapt around these differences.

Aric: Individual sensitivity varies greatly. Conversely, patients taking high doses of Ambien often visit our clinic because medication alone fails when psychological or behavioral factors interfere.

Aric: Just as sleep isn't strictly controlled by medication, it isn't strictly ruined by caffeine alone. Ritualized relaxation and lower baseline stress provide strong compensation.

Aric: And ultimately they, you know, they we see it as outsiders, as bucking the trend. But it may just be kind of other compensatory things that might, help regulate someone's sleep effectively.

BrentWhat is your personal sleep environment? Do you use blackout shades, an Eight Sleep, or an Oura Ring? How cool is your room?

Aric: Even as a sleep specialist, I occasionally experience difficult sleep after intense clinical days. I track data using an Oura Ring and sleep on a standard mattress.

Aric: I have two kids, like, it's it's, you know, it's, it, you know, it's a stressful time. So I do have an aura ring I'm not wearing today because I think it had to charge, and I was like, should care for the podcast, but, you know, and I do track it. I have a regular mattress. I think it was like a hand-me-down mattress from, like some neighbor or something.

Aric: Living in San Francisco, we keep windows open year-round for cool air and fog. We have blackout curtains and fixed morning schedules tied to family life.

Aric: I deliberately avoid bringing work home, creating a clear psychological boundary that facilitates winding down.

Aric: My 13-year-old son and I watch TV shows together as part of our evening routine, establishing a consistent wind-down habit.

Aric: Keeping routines consistent removes anxiety about sleep quality.

Aric: Sounds amazing, but otherwise, yeah, I just kind of do the the regular thing like everyone else.

BrentI really enjoy the Eight Sleep temperature regulation, keeping our bedroom around 58–59°F. As a sleep researcher, what do you look for when checking Oura Ring data in the morning?

BrentIt's expensive, but I do, I do like I do enjoy it. It's pleasant. And then what for you on the aura ring? Are you looking for? So, like when, as a sleep researcher, when you wake up and you see it, like, in terms of the time you're sleeping or I want to ask you about the score again, but what are you looking for in the aura ring?

Aric: When wearables gained popularity, a condition termed orthosomnia emerged—insomnia caused by anxiety over tracking metrics.

Aric: I check data casually without letting score variations influence my mindset. Interestingly, if I feel tired but see a high sleep score ("crown"), my perception shifts positively.

Aric: And so, like, I'm like, if I get the readiness one, I'm like, yes, this is going to work out. But I think the thing that's interesting is like, sometimes I will it doesn't usually work the other way, but if I wake up and I'm like, that wasn't a very good night, then I look at it and it says, it's a crown.

Aric: I'm like, oh no, it's okay, I feel good, I feel good, you know? And it's so psychologically it's interesting. I don't I don't have the experience where I like I'm bummed out if I, you know, because usually I'm just doing my best. You know, it.

BrentWorrying about insomnia causing more insomnia is a tough cycle. Where can listeners find your work and book?

BrentWhere can we where can we? Yeah. Where do we find you? Where do we find your work, your book?

Aric: I am based at UCSF. My book, The Sleep Prescription: Seven Days to Unlocking Your Best Rest, is widely available in multiple languages. Distilling cognitive behavioral therapy techniques for public use has been deeply meaningful.

Aric: Hearing feedback from readers finding practical improvement in their sleep is immensely rewarding.

BrentThe book is The Sleep Prescription: Seven Days to Unlocking Your Best Rest. Doctor Aric Prather, thank you so much for joining us. It's been a pleasure.

Aric: Thank you so much. It was a pleasure.

Death Clock with Brent Franson is produced by Patrick Gudino, music by Patrick Lee, and recorded in Boulder, Colorado and San Francisco, California.
Dethklok with Brent Franson is produced by Patrick Gudino, music by Patrick Lee, and recorded in Boulder, Colorado or San Francisco, California.