The #1 Tool for Performance and Health: Sleep
I have always had a healthy respect for sleep. My father used to remind me that “sleep is an ally,” quoting Robert Ludlum’s Jason Bourne, the superhuman international intelligence operative who was the protagonist of The Bourne Identity and the accompanying series. Although when I tried to look this up, it appears the quote may be: “Sleep is a weapon.” Nevertheless…
After leaving the roost of my parents’ home, I went on to spend 11 years in higher education (“Learning, not earning!” I used to say with a smile), where the student bodies of the various universities did not widely practice good sleep hygiene. After graduating from medical school, I then spent six years training to be an orthopedic surgeon. In this setting, sleep deprivation was considered part and parcel of the education of a surgeon. Nevermind that western European countries produced fine orthopedists through training 50 hours per week. In the US, the ACGME’s tilt towards a less sleep-destructive training system involved capping resident hours at 80 per week.
Weeks before I was to finish this training, my wife gave birth to premature twins, one of whom required ventilator support for over a year. We soon learned what the availability of in-home pediatric nurses with specialty training in tracheostomy care was like in central Pennsylvania. As my wife and I took turns laying down next to the ventilator to listen for alarms, we would pass each other in the hallway halfway through the night, trying to split the night so that we could each grab a half night’s sleep before going to work the next day.
At some point, through socialization, my own choices and circumstance, I had lost touch with what it meant to sleep soundly and feel well rested. As my children began to surpass their early challenges, the prospect of restful sleep seemed tantalizingly achievable once again. Even without a mini-ICU in your kid’s bedroom, whole-home sleeping can be challenging but we were ready to chip away at the challenge.
I knew the basics of sleep hygiene, but as with many human behaviors, knowing what is good for you and doing it are not the same. Ask any smoker or anyone who struggles with their weight. The first step in reclaiming a restful night was to get the kids on board. Admittedly, this is still a work in progress with our now school-age children, but we knew we were dead in the water as far as sleep was concerned if another human was constantly interrupting it. We also wanted the benefits of sleep for our kids. Having finally gotten past the point of oxygen monitors and ventilator alarms, we now had a chance.
Much ink can and has been spilled on the vast topics of baby and child sleeping, so I won’t get into it here, but I will say that of the books I read, The Sleepeasy Solution helped most.
My first personal intervention, in 2020, was to start waking up at the same time each day. (Only later would I pair this with going to bed at the same time each day.) Currently I set a vibrating alarm on my watch to minimize household noise. I very briefly experimented with waking up to the sound of Rick Ross’s Every Day I’m Hustlin’, cued up to the chorus. ‘What better way to set the tone for the day and GET AFTER IT!’ I thought. Unfortunately, I did not alert my wife to this plan. Let’s just say that practice lasted exactly one day.
I used to set my alarm based on what I needed to do and where I needed to be by what time the following morning and arrive at a time based on subtraction. On days where I was in surgery, this would be in the five o’clock hour. On clinic days, it could be as late as 6:30. I settled on 5:00 am as my wake up time. This would allow me to get to the hospital on time regardless and most days would allow some extra time in the morning. Since the 5:00 am wake up was predicated on making it to surgery on time, I dubbed it the ‘Single Orthopaedic Wake Up Time,’ i.e. the SOWUT. Embracing the SOWUT, even on weekends, went a long way toward regulating my sleep.
Also in 2020, I abandoned the use of my bedside lamp in favor of a small amber reading light, in order to minimize blue light exposure to my eyes before bed. My wife picked out a pair of lovely bedside lamps and tables to flank our bed. Mine is largely ornamental or used earlier in the evening. For my typical pre-sleep reading, I have converted to the blue light-free reading light to avoid the melatonin-blocking effects of LED-generated blue light.
In 2021, I focused on avoiding eating and drinking late. Large meals close to bedtime and alcohol wreak havoc on sleep quality. Our kids like to eat relatively early, so although it took some getting used to, a family meal between 5:00 and 6:00 pm actually suits everyone nicely, though it can be challenging to get it ready. Fortunately, in addition to being an amazing chef, my wife also has the uncanny ability to single-handedly prep and cook a gourmet meal in record time, all while fielding constant requests from the kids.
In 2022, I read Matthew Walker’s 2017 book entitled Why We Sleep: Unlocking the Power of Sleep and Dreams. He lays out rather comprehensively the how and why of sleep for humans and other animals. The book can become a bit of a slog at times when discussing sleep wave patterns and the science of REM (rapid eye movement) and NREM (non-rapid eye movement) sleep. Sections of this tome are certainly not ideal for those not scientifically inclined. However the book is written for the lay public and he does not leave any jargon unexplained. The chapters are written as stand-alone topics, thus releasing the reader from reading them in order or in continuity. I personally took some breaks to read other books in between chapters just to give myself a hiatus from sleep science.
The presentation of data was quite compelling. I knew that sleep was healthy and sleep deprivation detrimental, but this book enumerates study after study showing just how devastating lack of high quality, sufficient quantity sleep can be. Inadequate sleep is associated with cancer, heart attacks, shorter life span, decreased productivity, mental health disorders, and decreased athletic and academic performance. None of these associations were surprising, but the extent of the effects and how great the detriment to losing even one hour of sleep gave me a renewed appreciation for the benefits of slumber.
I have made several tweaks to my protocol in 2022. First, I started gathering data on my sleep quantity and quality using an Oura ring. You cannot objectively know you are improving something unless you can quantify it. When I learned of Oura’s transition to a subscription payment model, I briefly lamented the trend of the modern marketplace to the membership economy, but gamely ponied up, as the hardware seemed to be highly accurate based on my reading of reviews. In my experience, the biometric detection is highly accurate and it has been helpful to correlate how I’m feeling with sleep quality and see how behaviors and events during the day can affect my sleep. Another big take home: time in bed does not equal time asleep. We need to allow extra time in bed since even good sleep efficiency may only be around 85%.
I also placed a small, digital thermometer on my bedside table. The ideal sleep temperature is 65 degrees, with temperatures over 75 being detrimental. This is a challenge in our house. Not everyone wants the same temperature, and in the summer, the ambient temperature can be well above 75F at night, while the air conditioning can make it too cold. Nonetheless, the thermometer can guide how much to wear to bed and whether to use sheets and blankets.
To further ward off the evils of LED blue light, I purchased a cheap pair of blue-light blocking glasses. I can’t honestly say I have noticed any difference in how I feel or how I sleep, but I don these starting at sunset nonetheless, as it seems like a harmless intervention with some potential upside. Also at sunset, I have embraced a digital sunset - no screen use after dark. It’s like time-restricted eating but for your digital devices. I go for a 12 hour fast for both food and phone each night, having removed the phone from the bedroom unless I’m on call for the hospital. The same goes for night caps. A drink at the end of the night always seems like a good idea before you have it, but rarely after, and your sleeping self will thank you to avoid it.
The next intervention required somewhat of a leap of faith. I was curious to see if nose-breathing versus mouth breathing at night would affect my sleep. Having a long history of mouth breathing, both daytime and nighttime, I knew this would involve some active intervention. I would routinely wake up with a dry, cotton-mouth feeling in the morning, sure that I had breathed through my mouth all night, a suspicion confirmed by my loving bedpartner. I decided to try mouth taping. Naturally, I was afraid I would suffocate. At first, I tried just taping the center of my lips, making sure I could suck air in through the corners of my mouth if necessary. On some nights, this ended up happening, but on a good night, the cue to keep the lips closed was enough to make me stick to nose breathing. Gradually, I gained the confidence to cover my whole mouth with tape. No, I did not die during the night. Great. That would have been a bummer. However, it wasn’t until I combined mouth taping with a BreatheRight Nasal Strip that I unlocked the true power of this technique. I had tried the nasal strips before with little effect in isolation. But in combination, the results were much better. Adding in a spray of saline in each nostril before bed, the outcome was a rejuvenating night of nasal breathing.
Here is my current protocol:
First thing, check Oura score from the night before and reflect.
Then exercise is typically undertaken first thing in the morning.
One cup of coffee in the morning. If anything additional, no caffeine after 2:00 pm.
Dinner as early as practical. Aim to finish eating ideally by 6:00 pm, definitely by 7:00 pm.
No drinks (alcoholic or non-alcoholic) after dinner.
Wrist watch alarm set to 7:00 pm every day, as a cue to start the bedtime ritual for the kids (bathe, brush teeth, read stories, sing songs). Lights out for kids at 8:00 pm.
Bedtime routine: journaling, foam rolling/stretching, spending time with partner, brushing teeth/washing face. Reading (usually a novel) with amber light. Check the temperature. Tape mouth closed, apply BreatheRight nasal strip.
Here is a nice, succinct list of sleep hygiene practices from the NIH:
Adhere to a regular sleep schedule
Avoid exercise late in the day - not within 3 hours of bedtime
Avoid caffeine and nicotine
Avoid alcoholic drinks before bed
Avoid large meals and beverages late at night
Avoid medicines that delay or disrupt sleep
Avoid naps after 3 pm
Relax and unwind before bed
Take a hot bath or shower before bed
Optimize your sleeping environment (eliminate light and distractions, optimize temperature)
Get exposure to (morning) sunlight - at least 30 minutes
Don’t lie in bed awake - after 20 minutes, go do something relaxing until urge to sleep returns