[2020-10-16] The Sleep Solution

As I promised in More on sleep, I'm returning with a post based on The Sleep Solution: Why Your Sleep Is Broken and How to Fix It. I finally finished this book by W. Chris Winter, MD. While it's long, it's well worth the read, especially if you struggle to sleep when you want to sleep. For those of you who don't have the time to read the book, I've compiled my favourite passages from The Sleep Solution. If this whets your appetite, you can purchase the book or borrow it from your local library.

Having the time to focus on my health means that I've never been in a better position to get good sleep. That's not to say that I've figured everything out. I haven't. But I am starting to implement some of the ideas that Winter puts forward in his book.

As tempting as it would be to jump to some of the quick tips and trips (they're coming—I promise), I would not be doing justice to The Sleep Solution if I didn't cover a few key points from the earlier chapters of the book (direct quotes are in italics).

Winter insists on the following:
  • Sleep complications are treatable ([T]hink about sleep as one of the foundational processes within your body that you can actually change.)
  • Sleep is vital to health, including helping us maintain a healthy weight, supporting a healthy heart and circulatory system, elevating our mood, and supporting our immune system. (Your body is doing amazing things at night while you sleep.)
  • We all sleep, even those who say "I can't sleep." (The medical fact is, we all sleep. It's a primary drive. The body insists on it. So the first thing I need to tell you if you are one of those people who "never sleep" is this: you need to accept one simple fact, or you will be doomed to struggle with your sleep forever. You sleep.... Do you sleep well? Maybe or maybe not, but you do sleep.)
  • The reality of our sleep and our perception of our sleep are not always in sync. (To some degree, stages of sleep and an individual's perception of sleep often constitute whether an individual considers himself a good sleeper, a light sleeper, or in many cases a poor sleeper.... Sleep itself has three important phases. The foundation state is light sleep. Notice how light sleep serves as the passageway between wakefulness and deep sleep. Deep sleep is our most restorative sleep but you have to pass through light sleep to get there.... The third kind of sleep is dream sleep [REM sleep]. Dream sleep is when the vast majority of dreams occur.)
The most important tip in The Sleep Solution is to have a routine that promotes good sleep. This includes the same waking time every day, exercise in the morning to promote wakefulness, consistent meal times, and a period of winding down in the evening. Winter points out that kids aren't the only people who would benefit from a set bedtime and routine.

[A]n adult's sleep routine might look something like this:
    • Exercise in the morning, preferably in bright light.
    • Consistent breakfast timing with the meal heavy on wake-promoting protein.
    • Consistent lunch timing.
    • Finish dinner at least three hours before bedtime. If you have to snack after that, have a handful of nuts or a few pieces of dried fruit. Not too much.
    • Reduce your environmental lighting around the time the sun is going down. Turn off lights or use dimmer switches.
    • Spend an hour after dinner jotting things down on your to-do list. Put the list away after sixty minutes.
    • Brush your teeth.
    • Take a warm bath.
    • Do some light exercise or meditation. Breathe deeply.
    • Read a print book until you feel sleepy.
    • Turn out the light, and snuggle into a cool bedroom environment.
This recipe for a good night's sleep appears in a chapter on sleep hygiene. Winter explains:

Sleep hygiene is the act of controlling your sleep behavior and environment in an effort to optimize your sleeping. Basically, it's doing what you can to set yourself up to sleep successfully. It is controlling what you can control.

Expanding on a few of the points above, Winter says that we should make our room as dark as possible, beginning with no television:

A big source of light is the television. Why did televisions wind up in the bedroom? I don't have a clue. To me, it's like a toilet in the family room. Television produces loads of light. This high degree of light intensity in addition to the noise and stress they produce can significantly worsen sleep. Also, the television is conditioning you to need it to fall asleep. Not good. Watch your TV somewhere else.

Screens of any type are prohibited.

[T]urn off your smartphone, laptop, tablet, or any other electronic device. Completely off. That light is killing your sleep. In a 2014 study by Charles Czeisler, individuals who used e-readers before sleep at night took an average of 10 minutes more to fall asleep and had less REM sleep than individuals who read a printed book with indirect light. Any light exposure in the late evening or early night can have a negative impact on your circadian rhythm and sleep, so keep your environment dim at the end of your day for great sleep. If you must use light, try either to filter out the blue and green from your device or consider wearing blue-blocking glasses. Screens and similar lights should be turned off several hours before going to bed.

Your sleep environment should be comfortable. This means:
  • a good mattress (The main thing is be comfortable and don't get suckered into buying a bed as a cure for all of your sleep woes. If your bed is hideously uncomfortable, upgrading might be quite helpful, but be smart with your money. Comfort, that's all you need.)
  • comfortable bedding: flannel if you tend to get cold at night, sheets that wick away moisture and sweat if you get hot at night (you should love your bed)
  • a comfortable pillow (Do you even like your pillow?...find a new one to sleep with, sleep with several at a time and keep the one you like best.)
  • comfortable sleepwear (I typically encourage people to wear less, not more to bed.)
  • a quiet clock that does not light up the room (It’s best if you can't see what time it is when your room is dark.)
  • a soothing colour on the walls (a soothing blue gray is best for sleep)
What we take in during the day, and when, can also affect our sleep. Winter recommends the following:
  • Stop smoking, especially anywhere near the time you are going to bed (Nicotine is a stimulant. It will keep you awake and worsen the quality of your sleep once you fall asleep.)
  • Cut down on caffeine, especially in the evening (It keeps you awake and makes you pee.)
  • Avoid alcohol (It worsens the quality of your sleep, leads to awakenings at night [often to pee], worsens breathing problems at night including snoring and choking [apneas], and may magically produce surprise bed partners in the morning.)
  • Stop eating two to three hours before your bedtime, especially foods high in protein
  • If you must eat before bed, choose foods with a high-glycemic index (e.g., dried fruit, cereal and bananas) or foods that are high in melatonin (e.g,. walnuts, tart cherries), tryptophan (e.g., chickpeas), magnesium (e.g., almonds) and calcium (e.g., milk)
For those of us who can't turn our minds off when the lights go out, Winter recommends this trick:

So try this: get a notebook and before getting in bed, write down the things on your mind. Practice restricting this writing to an hour-long period in the evening. At any point during this designated hour, you may write things down in your notebook that are on your mind. You do not need to write continuously. Once the hour is over, put the notebook away. You are no longer allowed to think about things you have to do. There's enough on your list already.

One final suggestion for a bedtime routine:

One useful component to the bedtime routine is a hot shower, or preferably a hot bath. While cooler environmental temperatures typically result in a higher-quality sleep, vigorously heating the body via bathing before sleep has been shown to improve sleep quality, most likely because of the cooling and body heat release that follows. Therefore, a hot bath about an hour before you hit your cool, comfy bed can be very helpful for difficult sleepers.

For those who suffer from insomnia—which Winter defines as not sleeping when you want to sleep and caring a lot about this fact—the doctor states that resting in the absence of sleep is still beneficial:

In 2005, neuroscientist Gilberte Hofer-Tinguely showed resting without sleeping improved cognitive performance. Resting is not wasted time; in fact, a 2009 study revealed that for some cognitive tasks, the benefits of resting are indistinguishable from those of sleep. So don't worry too much about getting into bed and not sleeping immediately or having a prolonged awakening during the night.

He also maintains that anxiety, including worrying about not sleeping, is often the cause of insomnia:

People who suffer from insomnia often put mental pressure on themselves to get to sleep at night. Many people worry that if they "don't get to sleep sooner" their productivity will suffer at work or they will feel exceedingly bad during the day. Their anxiety about the consequences of not sleeping ratchets up to fear, and before long, they are in such a state of vigilance that they are as far from sleep as it's possible to be.

Winter contends that bad sleep is much more dangerous in your mind than it is in real life.

For those who struggle to fall asleep or to stay asleep, Winter proposes a sleep restriction exercise called the Ice Bucket Sleep Challenge:

If you have difficulty falling asleep or staying asleep, this is a wonderful exercise you will thoroughly enjoy!
    1. Determine what time you need to wake up and set multiple alarms for that time.
    2. Fill a bucket with ice water and set it near your bed. Instruct your spouse to pour it on you if you don't wake up with the alarms scattered throughout the room.
    3. Work backward from your wake up time five and half hours. This is your new bedtime. In other words, if your alarm is set for 6:30 a.m., your bedtime is now 1:00 a.m.! Exciting... you are going to get so much done!
    4. The rules are simple. You can go to bed at your bedtime or anytime after. Not sleepy at 1:00? Feel free to stay up as late as you like!
    5. You must be up and out of bed by 6:30 or earlier. There is absolutely no sleeping in. Remember the bucket!
    6. Napping is not allowed. Neither are sleeping at your desk, falling asleep before dinner, nor napping on the couch in the evening. Sleep is not allowed at any time other than your nightly sleep period: 1:00 to 6:30 a.m.!

This sounds brutal (even tongue in cheek), but there's a method to Winter's madness:

As time passes with this exercise, the sleep disruptions that were once there slowly start to fade as the body desperately tries to satisfy its sleep by making the five and a half hours of sleep opportunity each night as efficient as possible. In other words, over time, provided you aren’t cheating (and hitting the snooze ten times is very much cheating—stop using it), your brain will begin to exhibit a stronger and stronger drive to sleep upon going to bed because it is coming to the conclusion that if it wants to sleep, those precious five and a half hours are the only time to get it.

Winter is not suggesting that 5½ hours of sleep is sufficient for most people. Now that the fear of falling asleep has been addressed—without the aid of sleeping pills, TV or relaxation apps—it's time to add 15 minutes to the start of the sleep cycle: Keep that wake-up time anchored at 6:30, but move the bedtime to 12:45 a.m. instead of 1:00.... If excessive daytime sleepiness hasn't gone away, more manipulations of your bedtime (not wake time) need to happen until you can get into bed, fall asleep in fifteen minutes or so, stay asleep, and feel good the next day. Winter says that patients who undergo the sleep restriction exercise typically need 6½ to 7 hours of sleep.

Because sleep is so important to my recovery, I'm making a point to turn out the lights by 10:00 p.m. While I don't set an alarm, I often wake up at 6:00 a.m. Sometimes I read the news on my phone before getting out of bed, but I make sure that I've had my breakfast by 7:00 so that I can go for a walk with my son. (Today was a big step day: more than 16,000 steps as of this writing.) I'm trying to opt for low-light tasks at night, such as reading paper books, though giving up screen time is hard for me.

This is a long post, but I had so much that I wanted to share from the book. You'll find additional information in my favourite passages from The Sleep Solution and way more in the book itself. Happy sleeping!

Photo credit: Amazon.ca