The Sleep Playbook

Vishesh: The helpful technology is extremely low tech: avoiding light at night. Great idea, especially if there's ambient light. Eye shades: wonderful idea. A consistent bedtime: you don't need anything more than a clock for that, right? If you don't have a sleep disorder, that's all you need. All this other stuff is meant to sell you something.

Brent: Welcome to Death Clock. I'm your host, Brent Franson. Today, we speak with Doctor Vishesh Kapur about sleep. Doctor Kapur is a professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Washington. He's the director of sleep medicine, the program director of the UW Sleep Medicine fellowship, and the medical director of the UW Medicine Sleep Laboratory.

Brent: We try to cover all things good, high-quality sleep. We talk about medications. We talk about what to do before going to sleep and what you might do if you wake up during the night. He's a deep expert on sleep apnea, and we touch on sleep apnea as well. So this should be an episode that's relevant for everybody.

Brent: It covers sleep. And even if you feel like you know the basics—I mean, I feel like I'm very deep on all things sleep science—I found it to be a helpful episode, either in reinforcing what I already know or in learning some new things. He's a great guest. I hope you enjoy!

Brent: Doctor Vishesh Kapur, welcome to the show. Thank you. We had set up this conversation to talk about sleep apnea, and I want to touch on sleep apnea today, but I think it makes sense to widen the scope a little bit and talk about sleep more broadly. It's something that's been on my mind a lot.

Brent: We've talked a lot about it here on the show, but I think it's one of those topics you can keep coming back to because it's so important. But before we do that, will you just give us a sense of your bio and your background?

Vishesh: Yeah. I'm a physician. I went to medical school at Yale. I did my internal medicine residency at the University of Rochester, and then came to the University of Washington to do training in pulmonary medicine and got very interested in sleep medicine. I've been practicing sleep medicine now for over 25 years.

Vishesh: I have a background in epidemiology, so I've done clinical epidemiologic work, especially in sleep apnea. I also teach residents and fellows and have served in a number of national roles including clinical guidelines on treatment of sleep apnea and other issues.

Brent: I feel like people might not know this—I didn't know it until some number of years ago—that the medical school at University of Washington is among the best. I don't know if it's top three or top five, but I think we typically think of the undergraduate schools, and I know UW is great—and I'm not saying anything negative about UW—but we think about the Ivies. UW has an amazing medical school.

Brent: So is that still true or am I getting that right?

Vishesh: You're absolutely correct. If we look at the number of grant dollars that go to universities, University of Washington as a whole is one of the top in the country, particularly in the School of Medicine. I think if you're looking on the West Coast, it would be in the top two or three at least.

Brent: Let's start talking broadly about sleep. First, why did you get into sleep, and then on the back of that—this is a simple question, but I think simple questions can be hard to answer—how do you define sleep? What is sleep? When are we sleeping, and when are we not sleeping?

Vishesh: Two different questions. I got involved with sleep... the area I was involved with in pulmonary critical care was very acute care, and that didn't really suit my personality. I really enjoyed thinking about physiology and how it impacts people, using that kind of knowledge to improve people's lives. I got very fascinated by this disorder of sleep apnea, which was in its nascency when I was getting involved, and I really enjoyed discovering more about it and being there as the field developed.

Vishesh: It's been extremely interesting to see that base of knowledge increase and also the impact of the area increase. So that was your first question. Your second question was: what is sleep? Sleep can be defined in different ways. One is just by observing someone who's sleeping. Typically, someone is reclined when they're sleeping.

Vishesh: They're inactive, breathing gently, and are relatively unresponsive, though it's a reversible state. You can nudge someone and they'll wake up. If you're looking from the outside, that's what sleep is. Obviously, we want to look at what's going on inside the body. That started to be looked at in the 60s and 70s, when people started to make measurements like EEG measurements and things like that.

Vishesh: They found that brain activity is very different during sleep. It turns out it's not just one homogeneous state that's different than wakefulness; there's non-REM and REM sleep. So there's a distinct physiology to sleep that varies through the night. Then you can measure a number of other body functions that are different during sleep.

Vishesh: Your heart rate will go down, and different hormones will vary. It's an altered state; I guess the best thing to say is it's restful and necessary for life.

Brent: How do you think about... I think there's some controversy around this, or maybe there's just not one answer, but how do you think about defining quality of sleep and quantity of sleep? Do you think there's a good answer on how much sleep you should be getting, no matter who you are? And how do you know whether that sleep is high quality or not?

Vishesh: That answer is different depending partly on how old you are, though it becomes more consistent once you're an adult. Once you're, let's say, age 25 and greater, we know most adults need seven or more hours of sleep, but there's a significant biological variation there. So, I could do really well on seven hours of sleep.

Vishesh: But you may feel sleepy if that's all the sleep you're getting, and you may need eight or 8.5 hours of sleep. There is a quantity requirement for sleep. Just because you have very efficient sleep doesn't mean you can get less than your biological need for sleep. In response to your question about quantity... the other part, which is quality, you can certainly define that based on the different sleep stages you're going through.

Vishesh: How smooth the transitions are, the percentages of each... that's one way to define it. There are certain stages of sleep—deep non-REM sleep, which is often called slow-wave sleep—which seem to be extremely important in terms of paying off our sleepiness debt. It tends to occur at the beginning of the night.

Vishesh: There's REM sleep, which seems to be very important in certain areas like memory and emotions, and that tends to occur more near the end of the night. So you certainly can define sleep based on these kind of objective parameters. But I think just as valid is how you feel. Do you feel like you get a good night's sleep?

Vishesh: Do you feel rested in the morning? How do you feel through the day in terms of alertness? I think sometimes people get too focused on these objective measures, sometimes to their detriment, because there are devices out there that will measure things for you and say, "Oh, you're not getting enough of this and enough of that."

Vishesh: And I think it's really better for an individual to think about how they feel.

Brent: On the quantity of sleep, do you think on the bell curve of biological requirements, if we think about either end of the curve, there's going to be some group of people who need a lot less than average and some group of people who need a lot more than average? Where do you think the ends of that curve are on either side?

Brent: As an example, I've heard stories—I think people say this about Trump—that he only needs four hours of sleep and he's fine, that that's just the way he's biologically wired. And I'm sure there's another version on the other end: so-and-so needs 11 hours of sleep and they have to get that every night.

Brent: Where do you think the ends are? If somebody says, "Hey, I only need four hours," does that feel realistic? Is that too low, or are there some people who really only need four, in the way that you're saying you only need seven? And what might it be on the other side?

Vishesh: I put the average at about eight, and on the upper end I would say maybe about nine for a healthy individual. On the bottom end, I might say six and a half. After that, it becomes pretty rare. If someone really is only getting four hours of sleep and you talk to them in detail about their experiences through the day, you start to find out that they really are sleepy.

Vishesh: They'll be nodding off here or there, or saying, "Oh, I'm just taking a quick nap here or there; it's just a rest." But there's something off. What we know from population-based studies is that once you're chronically getting six or fewer hours of sleep, people tend to be unhealthy. They tend to gain weight.

Vishesh: Their blood pressure is higher, and things like that.

Brent: Are you measuring sleep in terms of time in bed, or is that time asleep?

Vishesh: That's a good question. When we're dealing with population-based studies, it's often people saying, "This is the amount of time I spend in bed," or, "This is the amount of time I think I sleep." When I'm talking about what I think is ideal for people, I'm talking about the amount of sleep they get.

Vishesh: I would say seven hours or more of sleep, but it's really hard for someone to know how long they slept. A useful measure for yourself is: how much time am I in bed? That means I can't sleep more than that, right? So it puts an upper limit.

Brent: How do you think about interruptions to sleep? So if there's one person who had seven hours of sleep, no interruption, and there's another person who was in bed a little bit longer but still got the seven hours of sleep, but they got up to pee in the night, or they got a glass of water or something. What do you think about the difference in quality of sleep between those two examples?

Vishesh: In my gut, I think it's nicer to be able to sleep continuously and wake up, because when you wake up, you're coming into a late stage of sleep, and as you're going back to sleep after that wake-up episode, you're transitioning back into sleep. There's maybe something lost in all of that. But the reality is, especially as we get older, it's hard for us to maintain sleep continuity.

Vishesh: And there are things that wake us up—a need to urinate, for example, is very common. That's just what you have to deal with. Maybe you compensate by sleeping an extra 15 minutes or spending extra time in bed because you need to get back to sleep and get into deeper sleep. I would say in general it's better to have it continuous.

Vishesh: If there's an awakening, it's okay, especially if you get back to sleep very quickly. But longer awakenings change the dynamic of that quality aspect.

Brent: On this note, I think it's worth talking about the relationship that we have with sleep. If I were to very simply summarize insomnia, it is that you're constantly thinking about the fact that you don't sleep, so you don't sleep. There's a scary cycle that happens there.

Brent: I'm sure there are different types of insomnia caused by other things, but a common form of insomnia is this obsession about not sleeping well causing you to not sleep well. How do you think about the importance of that psychological relationship you have with your own sleep? Does holding on so tightly to making sure you don't wake up in the night actually contribute to the problem?

Brent: How important is that psychological state in terms of your relationship with sleep?

Vishesh: I think that's extremely important. There are different extremes in our society. There's the extreme of not giving yourself enough time to sleep. I see people who give themselves six hours or less in bed. Those people often have no trouble falling asleep because they're really sleepy when they go to bed and sleep right through, but they have a terrible time waking up and feel sleepy during the day.

Vishesh: That's the type of person who's just not prioritizing their sleep, or maybe can't prioritize it. On the other hand, you have people who get very focused on their sleep and go to the other extreme: "I want to make sure I get enough sleep, so I'm going to go to bed earlier."

Vishesh: "I didn't sleep well last night, so I'm going to feel really bad today, so I want to make sure I sleep well the next day." That kind of psychology is just not very helpful for sleep because sleep is an automatic process that happens naturally.

Vishesh: You can't try to fall asleep. What paradoxically happens is when you try to fall asleep or try to spend more time in bed to compensate, your sleep gets worse. I brought up this issue of looking at objective measures. These days, some people get very obsessed about their smartwatches telling them about sleep.

Vishesh: I see people who say, "I'm waking up five times per night." I ask, "How long are you awake for?" "I'm not aware that I wake up; my watch tells me I wake up five times a night." So there may be nothing to fix, but now a problem has been created.

Vishesh: Right.

Brent: Do you think people have an accurate perception of their own sleep? I remember talking to a sleep expert one time who said something to the effect of: people feel like they're up all night and never sleep, so we bring them in to do sleep studies and then they sleep. When you're unconscious, you're not aware that you're not conscious; you're only aware of the times that you are conscious.

Brent: Maybe that person is waking up a few times during the night and is aware of it—different from the example you just cited—but they think their sleep is much worse than it actually is. Do you think it's common that somebody is just not self-aware about the quality of their sleep or how much they're sleeping?

Vishesh: Yes, that's a very common phenomenon, especially in folks who have insomnia. It's called sleep state misperception. When people are struggling with an inability to fall asleep or stay asleep and you ask them how long they slept or how long it took to fall asleep, they'll usually report their sleep is much worse than what you can objectively measure.

Vishesh: It speaks to the psychology of sleep. On the other end of it, there are people who don't get enough sleep and are quite sleepy during the day, but they don't recognize it. They'll say, "Oh, I feel great," and then a spouse in the room will say, "No, you fall asleep whenever you sit down."

Vishesh: There's a lot of misperception that can happen when you're dealing with disordered sleep, whether it's not enough sleep or an inability to fall asleep. We get into a state where we can't really perceive what's actually happening.

Brent: Do you think those people aren't aware that they're not sleeping well or enough just because they don't know any different? They're just used to it, so they don't know what a well-rested waking state feels like. If you carry a weight around long enough, it becomes normal, and you don't realize you're carrying it until somebody takes it off.

Brent: Is that what's happening there?

Vishesh: There's a good bit of that going on, as well as a good bit of rationalization: "Well, I don't really need that much sleep." So they make their whole reality coincide with that belief.

Brent: You've alluded to this a couple of times: devices intended to help are possibly an issue. I've got an Oura Ring, and I've been wondering recently... I'm thinking about getting a good sleep score, and I think that's counterproductive to my goal of getting good sleep.

Brent: I'm somebody who's struggled with sleep for a long time, and I've got my own checkered history regarding my relationship with sleep. But we also have an Eight Sleep, which I think is pretty good, and we've got blackout shades in the room and a very strong air conditioner—we like to keep the room cool.

Brent: How do you think about advances in technology? Which of those are going to be helpful—where you put them in the category of a real step forward in improving quality of sleep—and which are neutral, a step backward, or don't deserve the hype?

Vishesh: The helpful technology is extremely low tech. You named some of those technologies: avoiding light at night, blackout curtains (great idea, especially if there's ambient light), eye shades (wonderful idea—try it out and see how deep you go), avoiding noise at night (wonderful—use earplugs if needed), a consistent bedtime (you don't need anything more than a clock for that), a consistent wake-up time, enough time in bed, a comfortable mattress, and a comfortable room temperature. If you don't have a sleep disorder, that's all you need. All this other stuff is meant to sell you something.

Brent: So you don't wear an Oura Ring or have an Eight Sleep?

Vishesh: I've got this Google device by my bed that tells me stages of sleep. It's there because I'm a sleep doc and was curious what that technology can show, but it's not something I use to improve my sleep. What I need to work on is not using my cell phone in bed, going to bed at the same time, and turning off the lights.

Vishesh: I know that's what's going to help.

Brent: Okay? Get the basics right before you go.

Vishesh: Don't go crazy at all—just get the basics right, because 95% of people don't get the basics right.

Brent: Let's say I got the basics right and then add the device. Do you think there's some chance devices are actively negative and have the opposite effect of what I might want?

Vishesh: Yes. As we were talking about, sleep is a natural, automatic process. If you put too much thought into it, you're interfering with that process.

Brent: Do you have an opinion on the temperature of the bedroom? My rule of thumb—as the pseudo-expert here because I sleep every night, though I'll ask the real expert—is that it should feel cold when you get in bed. You should be a little bit uncomfortable when you're not under the covers.

Brent: When you are under the covers, you're warm and feel good. That mimics what camping or sleeping outside might be like: the temperature in the space cools off and is a little cooler than would be comfortable in those clothes.

Brent: Then you've got the blanket, and that's an ideal sleeping temperature. What do you think?

Vishesh: You're capturing something there. In some ways, letting your body cool down at bedtime facilitates sleep, so you don't want your room too warm. You want it a little bit on the cool side. Obviously everyone is different, so if you disagree and feel your sleep is wonderful when it's warmer, keep doing that.

Vishesh: On average, it's better to have a cooler environment to let your body cool down.

Brent: I had thought that if I wanted to be cool before going to bed, I should take a cold shower, but I think I've been disabused of that notion. You might actually want to take a warm bath or shower, because when you warm yourself up and get out, your body wants to cool itself down.

Brent: That's a more effective state for sleeping. How do you think about artificially making yourself cool or warm through a shower or bath before bed?

Vishesh: There's evidence for that. The ideal is to warm up your body with a warm bath, and then as you get out and go to bed, that cooling process facilitates deeper sleep.

Brent: Switching gears a little bit, how do you think about sleeping pills and how helpful they are? I'll give a little of my background: I was misdiagnosed as bipolar in high school and put on Seroquel, which is an antipsychotic. It's pretty powerful—a "shut the lights out" kind of medication.

Brent: It really turns you off. So I was sleeping, but then I was a rebellious kid—drinking, taking Seroquel, and doing everything you shouldn't do. Then I realized Seroquel was bad, so I switched to Ambien and trazodone.

Brent: I went through all of them. My opinion now is that these sleeping pills are terrible and nobody should take them or start taking them, and I'm upset with the psychiatrist who prescribed Seroquel in the first place. That's a jaded and extreme position. I assume there's a place for these things, but usage of Ambien seems to have gone way down and been vilified a bit.

Brent: Seroquel, I don't know where that stands, but it seems trazodone is prescribed fairly often. How do you think about sleeping pills? What caution would you give around them? Just listen to your doctor, or only use them in certain cases?

Vishesh: The way I think about it is: what are you treating? There are some things that might need a sleeping pill, and other things where a sleeping pill is the wrong answer. If you're awakening at night because you drank alcohol at the start of the night and there's a natural wake-up, using a sleeping pill to treat that is not productive.

Vishesh: Get rid of the cause—get rid of the alcohol. Or if I have obstructive sleep apnea and am waking up repeatedly and someone puts me on trazodone—which is a common story—I'll stop waking up at night, but that's not the answer. First, treat the primary cause.

Vishesh: Some types of sleeping pills really should not be used because they're not actually sleeping pills. Seroquel is a major psychiatric medication not designed for sleep, and it's overused. That's one that would never be in my armamentarium for someone without a psychiatric disorder needing that medication.

Vishesh: Some sleeping pills are vilified while others are considered safer, and that perception—even among physicians—is not accurate. For example, trazodone is heavily used in primary care, but it's not FDA-approved for sleep. It can work in some individuals, but it doesn't always have a great side-effect profile.

Vishesh: Zolpidem is FDA-approved for sleep, but primary care physicians hardly ever prescribe it. I've seen patients put on Seroquel—which should never be used for sleep in someone without a psychiatric indication—instead. There often isn't a rational use of sleep aids when there is a need for them.

Brent: What are the cases where we would say, "Definitely a sleep aid"? Coming from my jaded perspective as someone who feels poorly treated and took a long time to learn how to sleep naturally, people go to their primary care physicians, say they can't sleep, and get prescribed Seroquel, trazodone, or Ambien without much thought. Those drugs can be very hard to get off of and can make the situation worse. People also use Xanax and benzodiazepines to sleep.

Brent: I would guess the majority of sleeping pills shouldn't be prescribed in the first place. What do you think that number is, and in what areas would you say sleeping pills are definitely the answer?

Vishesh: I agree that there's an overuse of sedative medications to help people sleep. On the other hand, there are individuals for whom FDA-approved hypnotic medications are needed, and when applied appropriately to that subset, it's an important treatment that improves quality of life. It comes down to having a clinician evaluate what's going on with you.

Vishesh: Saying "this person's not sleeping, let me prescribe something" leads to a lot of people getting something they don't need. On the other hand, if a clinician looks at all other possibilities and rules out sleep apnea or other issues, that's different.

Vishesh: If you have a physiologic predisposition to very light, disrupted sleep that hasn't improved through behavioral means, you could be treated long-term with a sleeping pill like zolpidem and do quite well. But that's a very selected individual.

Brent: Are there situational use cases? If I'm being treated for cancer and a side effect is bad sleep, or I'm going through a hard time... I'll bifurcate these two questions. Being treated for something where a byproduct is bad sleep feels like one thing, where we say, "We're going to help out." But on the other hand, if someone lost a family member, is experiencing grief, or is going through a hard time at work, is there a good use for sleeping pills in both cases?

Brent: I assume in the cancer case there is, but using sleeping pills for the rough-and-tumble nature of life is more complicated. How do you think about cases that aren't just a genetic predisposition to light sleep?

Vishesh: Short-term use of an FDA-approved hypnotic when something is going on that could reasonably cause a lot of problems—for a week or two—is a good reason to use a sleeping pill. If I come back from a trip and can't sleep because I'm jetlagged, but I have to get back to work...

Vishesh: If you're in a situation where you can't sleep and have a stressor going on, it adds to the whole stress around sleep and could create a chronic problem by making you really worry about sleep.

Vishesh: So using something for a week because you're dealing with something very stressful and need relief is reasonable.

Brent: Have you ever taken sleeping pills?

Vishesh: I have.

Brent: In those situational use cases?

I usually use it if I'm traveling through time zones and need to go to bed earlier, or if I'm on a trip in a totally different time zone and on vacation and want to make sure I get good sleep.

Brent: So for travel, a prescription sleeping pill on a short-term basis can be helpful. What do you think about supplements? Melatonin comes to mind, but increasingly we look at magnesium or L-theanine as being helpful for sleep. How do you think about supplements and their role in assisting with good sleep?

Vishesh: What potential do they have for harm? With something like magnesium, the chance for harm is very low unless you have kidney failure and can't get rid of excessive magnesium. Quite frankly, there's a huge placebo effect. When you look at randomized trials comparing a sleeping pill to a placebo, the placebo does pretty well too.

Vishesh: There's nothing wrong with taking magnesium if you feel it helps, even if it's helping psychologically rather than physiologically. For many of these supplements, there's not a high level of objective evidence that they work. With melatonin, there's not great evidence that it works across large numbers of people.

Vishesh: Though I see people who say it works really well for them, and I say, "That's great, use it," as long as it's not at a very high dose.

Brent: Somebody here once said something that resonated with me regarding supplements. They were pretty skeptical and said, "Look, if there were any truth to that, a drug company would have made a slight change to the formulation, charged a lot of money for it, and crossed that barrier."

Brent: You can basically assume that anything that doesn't become a doctor-prescribed medication doesn't help in a meaningful way. It sounds like there's some truth to that with sleep supplements where placebo effects are real—and if you're getting a placebo effect, great; magnesium isn't going to hurt you.

Brent: But we don't have any great randomized controlled trials on over-the-counter supplements helping sleep.

Vishesh: I wouldn't go as far as that other individual, because there's a lot we don't know. I wouldn't say that everything useful is available in prescription form. I have a little humility with the whole melatonin thing because while trials don't show it works for the typical person, if a low dose works for you—whether placebo or a slight difference in physiology—it's probably not causing harm.

Vishesh: If it works for you, okay.

Brent: On the topic of things to do before bed, how do you think about the role of eating before sleep? There's an extreme version: Bryan Johnson, who focuses on extreme longevity, swears he has to stop eating by noon to get the best sleep.

Brent: That feels extreme and impractical to me, but maybe there's truth to it. Directionally, eating a huge meal at 9:00 p.m. and trying to go to bed at 9:30 is going to affect sleep. How do you think about food digestion and sleep, and what is ideal there?

Vishesh: A lot of this is informed by common sense and what sleep docs usually recommend. The general principles are that you want to have your calories earlier so you have time to expend them.

Vishesh: You want to give yourself a chance to digest food. You don't want your stomach full of food at bedtime producing acid that could cause reflux.

Brent: Eating 3 to 4 hours before bed gives your body time to digest food so you can be in a more rested state.

Vishesh: There's probably a lot of science behind this related to circadian rhythms. All your different organs work on a certain rhythm, so there probably is a scientific answer to the ideal time to eat.

Brent: I've wanted to experiment with skipping dinner to see what happens to my sleep, but it's impractical. We eat dinner as a family—it's an important community time for us. My wife is Italian, and she's going to be very unhappy if I sit at the dinner table and don't eat.

Brent: So I haven't experimented with it, but it wouldn't surprise me if being in a fasted state helped sleep—though that might be over-optimizing. How do you think about caffeine? Do you have a rule of thumb for when to stop consuming caffeine?

Vishesh: Caffeine is an antagonist for adenosine, which is a marker of sleep deprivation and need for sleep. That's why caffeine antagonizes the ability to fall asleep. Logically, you wouldn't want caffeine active close to bedtime.

Vishesh: People vary in how they metabolize caffeine and their sensitivity to it, so when to stop is an individual decision. As a personal observation, when I was 20 I could drink soda or coffee in the evening and sleep fine. Around age 40, I found that drinking coffee even at 1:00 or 2:00 in the afternoon caused trouble falling asleep.

Vishesh: When your sleep mechanisms are working perfectly, they can deal with disturbances; when they're not, you want to avoid them.

Brent: Going back to the psychology of sleep, my wife is Italian, and Italians have rules around coffee: don't have a latte past 10:00 a.m. because they consider it a meal, but having an espresso after dinner is fine.

Brent: In that culture, having an espresso after dinner is common. When I'm in Italy with my in-laws, dinner is at 10:00 p.m., which is insane to me. Having an espresso at 11:00 p.m. or midnight after dinner is unimaginable to me.

Brent: A portion of that population has no problem having an espresso after dinner and going right to sleep. Is that part of the psychology of sleep, or are those people just not sleeping well?

Vishesh: There's a lot of individual variation in sensitivity, just like with medication. I see patients who drink coffee in the evening and fall asleep just fine at bedtime.

Brent: That sounds like a nice skill. My father-in-law sleeps like a rock, just like my wife, no matter what, and I'm jealous of it. Let's switch to sleep apnea. What is sleep apnea?

Vishesh: Sleep apnea is an interruption of breathing during sleep that typically happens because of upper airway obstruction. The upper airway naturally narrows during sleep because the muscles keeping it open relax; that's obstructive sleep apnea. Less commonly, central sleep apnea involves the control of breathing.

Vishesh: That's much less common.

Brent: Is sleep apnea a condition of modernity? If we went back 100,000 years in a time machine and observed cavemen and cavewomen sleeping, would we find sleep apnea at the same rates as in modern humans?

Vishesh: Perhaps not at the same rates, but it would still be there. Those individuals probably were not as overweight as people are now, and they didn't live as long—dying at 30 or 40—so they didn't have as much chance to develop it.

Brent: Weight contributes to the propensity to have sleep apnea, and it's something we can develop as we age. That's why a lot of people have it without knowing it.

Vishesh: Those are two important risk factors, especially weight. But I want to emphasize that very skinny people can have severe sleep apnea as well, which is why I think people in caveman times had it too.

Brent: How is it diagnosed and treated? Most of us know about CPAP masks—if diagnosed, you sleep on your back with a mask that can be loud.

Brent: It's not great if you're dating someone. How is it diagnosed?

Vishesh: Generally, someone presents to a clinician with signs and symptoms. Loud snoring is a indicator that it may be present. If a bed partner notices you stop breathing, or if you wake up choking and gasping, those are strong indicators.

Vishesh: Other clues include how it impacts your sleep or daytime feelings: waking up repeatedly, waking up unrefreshed, or feeling excessively sleepy during the day. A physician would then order an objective test to measure if breathing is interrupted at night.

Brent: Is that test putting something on your finger to sleep with, or another version of that?

Vishesh: Recently, a lot of diagnosis is done at home with minimal gear. The core is measuring oxygen levels, as well as sleep disruption and interruptions in airflow.

Brent: There seems to be an issue with undiagnosed sleep apnea—a lot of people walking around have it without knowing, and their lives would be much better if diagnosed and treated. Is that right?

Vishesh: Figures show up to 80% of people with moderate to severe sleep apnea may be undiagnosed. That's changing over time with increased awareness and home tests, but a significant number of individuals remain undiagnosed.

Brent: If I'm fatigued, snore, my partner notices I stop breathing, or I wake up gasping, those are signs to talk to a doctor. The definitive test is straightforward, so there's no diagnostic risk or downside.

Brent: And it's going to give you an answer.

Vishesh: Home tests are good at picking up severity, which can be defined by how bad you feel or what happens to your breathing and oxygen levels at night.

Vishesh: Home studies are good at picking up oxygen issues. However, with subtle sleep apnea where sleep is disrupted without oxygen drops, a home test might miss it. If someone was sleepy and snored loudly but had a negative home test, I would order a full sleep study in a sleep lab.

Vishesh: If there's no other explanation for feeling poorly and you have signs and symptoms, you probably have sleep apnea.

Brent: The risk is a false negative. You want to be wary of complacency from a negative home test and get to the bottom of underlying symptoms.

Vishesh: If you tell me you're sleepy and your sleep is interrupted, I want to get to the bottom of what's bothering you.

Brent: When you say "sleep lab," is that a place where you spend the night?

Vishesh: "Lab" isn't a great name for it—it's basically like a hotel room, except you have sensors on you measuring sleep and breathing.

Brent: That sounds hard for me to sleep in, with sensors on me in a clinical or hotel setting.

Vishesh: In an outpatient clinic setting, exactly.

Brent: Treatment-wise, is it putting on the mask and sleeping with it every night?

Vishesh: There are a number of treatments. CPAP is first-line and very efficacious. Efficacy means that if you put it on and use it all night without issue, it gets rid of sleep apnea.

Vishesh: Where it falls short is effectiveness—how likely you are to feel comfortable wearing it and using it every night. A significant portion of individuals are not well served by the therapy.

Vishesh: A high percentage of individuals do very well on the therapy, love it, and don't find it bothersome. The machines aren't noisy, and there are many mask options available.

Vishesh: At least 50% of individuals started on CPAP find it to be a great experience, their symptoms improve, and they are quite happy.

Brent: When people struggle with sleep, it seems to come in two flavors: struggling to fall asleep (like my 9-year-old daughter, who sleeps until morning once asleep), or falling asleep easily but waking up at 2:30 or 3:00 a.m. and having trouble going back to sleep (which is my category). What is your advice for the second category?

Brent: For the person who falls asleep fine but wakes up in the night and struggles to fall back asleep?

Vishesh: That makes me think about what physically is waking you up. You might be aware that it's too hot or that you have to use the restroom, or you might not be aware—it could be something like sleep apnea. I would consider those things, but there's also a tendency for people to feel like everything needs to be perfect.

Vishesh: It's not uncommon for people to wake up once or twice and fall back asleep. Clarify the real impact on you, and realize that as we get older, our ability to maintain sleep lighter later in the night decreases after paying off sleep debt early on.

Vishesh: If we don't have the same mechanisms to keep ourselves asleep, waking up once or twice is part of life.

Brent: Last question: what are you excited about? Are advances coming in medications or devices, or should we stop with all that and nail the basics?

Vishesh: There's a lot of innovation in this space. For sleep apnea, the number of minimal diagnostic devices is increasing monthly. New therapies are coming out, such as hypoglossal nerve stimulation devices that stimulate the tongue at night.

Vishesh: There will be a medication coming out for sleep apnea within the next year or so. People are using weight-loss medications for sleep apnea. We also treat other disorders like narcolepsy and excessive sleepiness with very effective medications that improve quality of life.

Vishesh: There's a lot of innovation going on in sleep medicine.

Brent: Wonderful. Doctor Kapoor, thank you so much for your work and for your time.

Vishesh: Thank you.

Brent: Death Clock is recorded in Boulder, Colorado and San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by yours truly, Brent Franson, founder and CEO of Death Clock.