Welcome back to the podcast. I am joined today with Brandon Liu. He is an internal medicine doctor in his respiratory fellowship for two years. and we are going to be doing an episode on combating the negative effects of sleep deprivation. Hopefully this is helpful for you. If you are in medicine, there's pretty much no avoiding some degree of sleep deprivation, whether you're in training and you have to stay up for a large amount of time at time, or you are going through stressful events in your life and have insomnia and are cognitively impaired the next day. We're going to be talking about first, how sleep deprivation impacts the body. Hopefully this doesn't scare you too much because we all have sleep deprivation. It's part of human experience pretty much, but then we're also gonna be talking about how to combat it. How to combat it with things like caffeine, creatine, exercise, and light therapy. So welcome to the podcast. Thanks for having me, excited to be here. Yeah, so how about we just start out and give like the basics of sleep deprivation? Yeah, so again, yeah, I'm happy to be here. You know, this all started with me just being a bit curious on the evidence of sleep deprivation as, you know, ever in a medicine will go through quite early on like very extended periods of not being able to sleep and I was always curious, you know, ever in a medicine will go through quite early on like very extended periods of not being able to sleep.

And I was always curious, you know, everyone feels terrible when they don't sleep in the air or have been like chronically sleep deprived. But I was really curious how much does sleep deprivation actually impact us and what can we actually do about it if anything? Diving into the literature, it's pretty concerning actually how significantly just a single night of sleep deprivation can harm virtually every system in the body. So I think a lot of people have heard the phrase that if you're sleep deprived, It's equivalent to being legally drunk, right?

And when you actually look back at the study here, this is because they actually took a group of volunteers that volunteered to do a series of cognitive tests after a night of total sleep deprivation. Then they came back later, got drunk, and then did the same cognitive test. Just one night of sleep deprivation was equivalent to being legally drunk with the blood alcohol concentration of 0.05%. Part of the issue here is a lot of the time people don't realize how impaired they are after just a little bit of sleep deprivation. This was a beautiful early on study that really demonstrated just how significantly sleep deprivation impairs people's cognition. What's interesting too is we let a lot of, we'll talk about a couple of cool studies here, but we let a lot of people after not sleeping overnight drive home, for example, from the hospital. Of course, it's obviously against law to drive with a blood alcohol concentration of

up. over night drive home, for example, from the hospital. But of course, obviously against law to drive with a blood alcohol concentration of 0.05%. And remember, when you drink, the first thing to go is your ability to know how drinking is affecting. Exactly. Your decision making. And 24 hours of continuous sleep deprivation, it's like a 0.10 BAC. I mean, that's basically five shots, right? Like someone just took five shots of alcohol. It's incredible. And, you know, they didn't measure them in the study, but I think a lot of people realize, you know, the self-insight really dissolves away the more tired or drunk you are. You know, I have this awareness of this because when I'm more sleep deprived, whether I'm like, you know, kids are up in the middle of the night and I have to take care of them. Like the other night, my son had a nightmare and he comes in and then I'm trying to get him down and then I have to go back in and end up sleeping next to him because he was so scared. And so my sleep was wrecked, right? And so I played chess. My chess score was not, I was not doing well. My like, elo dropped. And so it's like your cognitive function just for one night, right? I've not sleeped well. It's crazy how fragile we are with one night of sleep deprivation. Yeah.

And you know, so the next question I had to was, you know, thinking more on the cognitive side of things, you know, through residency, every about four days on average, my first year, I was doing a 26 hour straight shift where, you know, sometimes you might get a little sleep, but a lot of the times none. And then the question is like, what do you do the next day? Right? Because I still had to get some work done study, you know, medical students will be doing the exact same thing and have exams coming up. And so the next question I had was, you know, if you really, you know, sit down, grind, try to memorize things, how much of a difference does it actually make when you're sleep deprived? Right? And Matt Walker, who is a very famous sleep expert, wrote a very beautiful paper on this actually. And the takeaway is that sleep, sleep deprivation is very, very bad for learning. So in one particular study, people stayed up for 36 hours. So pretty extreme sleep deprivation. And then they were asked to memorize a series of words. So the positive negative words that people tend to associate, remember better and the neutral words. People who were sleep deprived remembered 40% less than those who had slept. So if you're severely sleep deprived, you really, the last thing you should probably be doing is putting your time towards memorizing things. Yeah. And this is like, how do you study some students are just naive to this thing that like optimizing your sleep is actually optimizing your chances of doing well on a test. So in any step preparation, it's paramount to get eight hours of sleep every night to get good sleep. Yeah, that's good. Exactly. And you hear what people pulling all nighters and the evidence very clearly says that you should not do that. Just sleep as much as you can prioritize studying when you're not not sleep deprived, and it'll be better in the long run. Wow. And then this is probably more common, right? Because this one study that looked at people who get two weeks of six hours per night of sleep, talk about that one. Exactly. So then the next question is, you know, so most people aren't staying up for 24 hours straight, right? Most of the time people have, you know, busy things with work, kids, they're not sleeping a ton every night. And what's interesting is sleeping just six hours a night, directly being compared to one night of total sleep deprivation was equivalent in one study. And of course, you know, in the studies, it's dose dependent, right? The less you sleep, the longer you sleep deprived, the worse your cognition is going to be. But, you know, going through all these studies before with one night of sleep deprivation hurts cognition so bad, you can... there's the same effect with just slightly reducing your sleep every night for over a chronic period. Yeah. Okay. So let's talk about what is happening in the body, like biologically, when someone is acutely sleep deprived. Yeah. So there's also several metabolic and other physiologic effects. So So you can really just go through every single body system and you'll find a significant amount of evidence on the harm with sleep deprivation. So, people also, I think intuitively recognized that when you're not sleeping well, you tend to get sick more often. And there are studies even from the 90s showing that certain immune cells, like natural killer cells, which are supposed to fight off infections as the anterior body are reduced by up to 28%. From a metabolism perspective, the other thing that, you know, I realized a lot when I was sleep deprived quite a bit was I was making very poor food choices. You know, I'd be way more likely to order something out over Eads and get a dessert and eat more of it. And there's metabolic evidence to support this where if you took a group of healthy young men and just gave them two nights of four hours of sleep deprivation, they're leptin decreased by 18% and Grellen increased by 28%. And so these are your hunger hormones, where grellen, you know, I remember it from the step exam, Skurr, makes you more hungry. So that's increasing. And then leptin, your satiety or fullness hormone is also decreasing. So it's a perfect recipe for overeating and making bad food choices. Right. And you can see how chronically this would cause your weight to increase and and so on and so forth. Yeah. Exactly. And we also have a lot of retrospective data looking at cohorts, people that sleep less, they have a higher risk of all sorts of diseases, right? They have a higher risk of becoming obese, getting type 2 diabetes, blood pressure goes up. They have higher risks of cardiovascular disease, even cancer. So overall, you know, it'd be nice to have long term preventive studies on what we can do about this, but for now, based on the evidence, the best thing you can do is try to prioritize your sleep as much as possible. Yeah, and I think there's a chronic impact. It's what a lot of these things are talking about, like this chronic impact of sleep deprivation that goes on for years and years. I'm even thinking about the studies on physicians, physicians, suicide rates in residents are actually lower than the population. But for people who are in their 60s, it's higher. And I've been curious about that data. Why is it so much higher after a life of doing, medicine and sleep deprivation could be part of that, because it's just part of the life of a doctor to have some degree of sleep deprivation. And so I think that's part of our passion behind doing this topic today is like, okay, what can we do to ameliorate it? What can we do to improve it? How can we prioritize it? It really is the sleep is like the new status symbol of choice, right? That we should be aspiring towards. Exactly, exactly. And that's exactly what you said is, people dedicate their lives to medicine and it's such a great field, but also just with the culture, it's a lot of the times it's something that you just, you know, you just fight through it because everyone else does. And there hasn't been much of an emphasis that I've seen at least on what can we do about the people that are being sleep deprived? I know there's implementation of night float systems and such, but there's really no avoiding sleep deprivation. What exactly should people be doing to try to offset these negative effects? Yeah, okay. Interestingly, it's not just when someone is like create someone craving more fatty foods, more, you know, more high carbohydrate foods, but it's actually how the body is processing those high carbohydrate foods. Why don't you talk about that study? Yes. Yeah. So there's a lot of evidence on processing carbs, higher blood sugar after sleep deprivation. And that's probably from a variety of mechanisms. Probably more of a shift to a kind of sympathetic or fight or flight mode after a night of sleep deprivation. And then also a lot of hormonal changes with circadian rhythms being dysfunctional. But just to put this in terms of numbers, healthy people sleep deprived or not sleep deprived given a high carb meal. When you're sleep deprived, it takes 40% longer to clear the glucose and it takes a lot more insulin secretion to bring that down. And so it kind of mimics, you know, in this study what the author's kind of called an early diabetic state where, you know, you have relative insulin resistance where you need to increase your insulin, which has a lot of downstream effects elsewhere in the body and your glucose will will be higher for longer. So terrible, terrible recipe for glucose. I've seen this in the IOP partial we used to ice to run. We get patients referred from endocrine because they had out of control diabetes, they could not control it with any amount of the medications. And when someone is chronically, psychologically stressed and sleep deprived, it will be almost impossible to control your glucose, right? And you can see that in the numbers here and you can imagine how that would play out, right? If someone's on insulin, they're sleep deprived, they're gonna spike higher levels because the stress cortisol and the, you know, that fight and flight system. So it's really interesting. What about the brain health emotional regulation, amygdala reactivity? How does that change? Yeah, this is another thing I think a lot of people also can reflect on when they're sleep deprived where it's, it can be a lot harder to contain and regulate emotions. So researchers actually sought to characterize this. So they did FMRI looking at people's amygdala's after sleep deprivation and then exposing them to negative stimuli. And their amygdala after 35 hours of sleep deprivation was 60% more reactive to negative stimuli. And you know, this is a common thing you see in the hospital a lot or in other fields where people are sleep deprived, people are more likely to get upset, get into arguments, be harder to self-regulate. You know, and this is, I'll do couples therapy sometimes. And I'll, you know, once in a while I'll have a couple that they will be like, we will not go to bed until we figure this out. We will argue half the night, and I'll be like, wait a minute, let's talk about this. The more and more sleep deprived you get, the more emotionally reactive you're gonna get,

how about we like pause an argument

and then say, why don't we bring this to therapy, right?

After we've slept well, right? And that could be a big win for a couple that does that, right? It's like under no conditions, does it make sense? To have a middle of the night sleep deprived argument when you could have a well-rested one and your MiGdala is going to work better. That's a good point. I do hear that a lot actually. I didn't include the study in the show notes, but it also helped sleeping help solve problems, right, even without people knowing it. So if you give people a task, like a hidden task with a hidden rule that people are supposed to find to speed up how they can solve it. If you keep people awake that whole time, I think something like 20% will figure out the hidden rule, but if you let people sleep in the same amount of time people are trying to do this test, a significant amount more wake up and solve this hidden rule problem. So it just goes to show if you sleep, your brain is still working on problems and you do not need to stay awake all night if you can help it. Yeah, unless your brain like mine wakes me up in the middle of the night to think about problems, to think about patients, it's very common for that to happen. And one of the biggest wins I've had recently is if I wake up and I'm thinking about a patient, you know, I wish them well. And I pray for them, you know, like, I just think positive things for them. I wish them well, and I pray for them. I just think positive things for them.

I wish them well, and I kind of let that awakening do that,

and it's changed the meaning of it.

It's changed the meaning of it for me a little bit

from being like, oh gosh, why am I awake?

I don't wanna be awake.

So like, okay, I'm gonna utilize this opportunity.

So, okay, let's get into exercise and sleep deprivation. Let's do it. Let's do it. Yeah, this is pretty much the best thing you can do if you're sleep deprived. Like in the midst of the sleep deprivation or like to be ready for the sleep deprivation or in what context? So that's exactly the thing. thing. So the more you exercise beforehand and the more fit you are, the more it will protect you when you get sleep deprived. And the more sleep deprived you are, doing exercise right before an important task will help significantly improve how you perform. So one of the first studies I wanted to go over was this very interesting one where they took two groups of healthy young people and they did an eight day study period, right? So first two days where you know they let everyone be in bed for eight hours and then they broke people into three groups. So normal sleep, you know,

sleep at home, sleep restriction, where for five days straight they were only allowed to sleep for

four hours at a time and then sleep restriction and exercise, where still only allowed to sleep for

four hours at a time. But the middle three days, so for example, you know, this is a weekday or

throughout the work week, Tuesday, Wednesday, Thursday, they had to do high intensity interval training. And it wasn't the most, you know, time intensive, it was about 10 intervals of 60 seconds at your peak resting for 75 seconds. So you can do that in less than 30 minutes easily with a warm up and cool down. And then they did a series of tests to see glucose tolerance and how might a contraria were functioning and amplitude of diurnal rhythms, which is a measure of how well circadian rhythms are functioning, because you're supposed to get nice and warm during the day or early in the morning and then cool down at night. And it was pretty interesting. So, you know, as we've seen in several other studies, sleep deprivation causes a kind of acute phase of a diabetes looking state where you have increased glucose, you require more insulin to bring their glucose down, it takes longer. And sleep restriction group, their glucose, of course, with the oral glucose challenge test increased significantly more than the people that were sleeping regularly. But just doing those three days of high intensity interval training during that work week almost completely negated the effective higher glucose at the end of the week. There was also improved mitochondrial respiration, so your mitochondria are working better, but it didn't really seem to make a big impact on circadian rhythms, at least on the way they measured it. But this was one of the first studies I found early in my residency, like what can I do to help reverse all these negative metabolic effects. And I actually wore one of those DEXCOM or Libre twos and was monitoring my blood sugar. And I did notice interestingly the mornings after I was sleep deprived. I'd have much larger glucose spikes. But if I exercised more during those weeks, it really blunted it and it kept it normal. So if you are sleep deprived, exercising is probably the last thing you're going to want to do and it's going to feel terrible when you start, but I promise it's one of the best things you can do for just your overall health, but also to fight through a period of sleep deprivation. That's this is this is really interesting. I mean, it almost like negates some of the impact of the sleep deprivation to do the exercise. I notice this is this strenuous exercise. 90% is very hard. I'll go on. I'll go do sprints up a hill near my house in Florida. It's like an overpass. So I run up to the top of the overpass and walk down. And this is 90% is very hard. That's like very tough. And 10 sets of that. Yeah, that's intense. That's intense. And think about like as well, this is a young population. So it's even more important to know about this as we get into our 40s and 50s. It's like so much more important. It's like sleep deprivation is going to be even a bigger impactor. Yeah. And I guess I should say just from a practicality standpoint, like I do a lot of running in sprints and stuff too, but when I'm very sleep deprived, I'm more likely to get on the bike because I feel like I'll be less likely to get injured, but it's a lot of balancing the risks and benefits there because sprinting at 90% when you sleep deprived on a hill, you're probably a little more likely to roll your ankle or miss a little hole or something. So just be mindful of that. So once again, compared to the control, the people that just had the sleep deprivation, what happened to their mitochondrial related mRNA? So their mitochondrial respiration, like a function of how efficient or well their mitochondrial were working, worsened with sleep deprivation? Probably from an inflammatory state is my thought. And that significantly improved almost back to baseline with the exercise.

Okay, that's very convincing. This is a very common circumstance of like four hours a night

for a period of a week or whatnot. This is very... Exactly, you just have a tough week and you just

have to find the time 30 minutes, three times that week and you will reap the rewards. Okay. Let's keep going. Study number two. Yeah, I wanted to go through this one as well. It's very similar, but this one shows a bit more of the preventive effect that I talked about. So they took 11 physically active men, healthy guys and underwent 24 hours of sleep deprivation in one of two circumstances. So one group, again, high intensity interval training, the other group, nothing. And so this was two weeks before. So for example, if for example, in two weeks, you're going to have to stay awake for 24 hours on a Friday night and Friday during the day. This means you do a Monday, Wednesday, Friday session one week, Monday, Wednesday, Friday session the next week. This one, they did a little less intensity training, six sessions, or sorry sorry 8 to 10 to ten, eight to twelve intervals. Actually, it was about the same. Very similar, 60 seconds max effort, and then 75 seconds recovery. So again, another thing you can do in less than 30 minutes. And when you look, this study actually measured insulin, which is very helpful. So you can see sleep deprivation caused a pretty much a state of insulin resistance. Increased glucose levels significantly increased fatty acids as well. And for the group that did exercise before the sleep deprivation. So it wasn't the day of sleep, like the day after anything. This is just you're getting physically fit and doing a lot of hit leading up to the episode. Their insulin resistance came back exactly to baseline in this rested sleep condition, but improved mitochondrial function. It didn't completely reverse fatty acid increase, but it did reduce it a bit. So this is all the more reason that the more fit you are walking into a, you know, unknown day of sleep deprivation or not being able to sleep your regular amount, the better off you'll be. Wow. It's stark the difference with the high intensity interval training, how that prepares your brain for that insult. Exactly. And so I think this is why it's like paramount to have a regimen that we do on a regular basis. And if it's like Dr. Pewter, I can't do this by myself. I don't have the willpower. It's like find a group. There's a lot to different types of groups that you can meet with that put you through a high intensity interval training. And if you're completely unexercised, then start somewhere. It doesn't matter where you start. Okay, let's go to the immediate cognitive boost of exercise and on sleep deprivation. Yeah, so this was so the other question I had after this was, you know, I'm sleep deprived so much or I was during my residency and the days that I didn't sleep, what can I do to, you know, if I need to get some work done or need to perform well, like, what can I do? And we'll talk about creating a little bit, but this was a very cool exercise study where they took students, um, sleep deprived them for 24 hours, similar to what a lot of residents do. And then they gave a series of cognitive tests. But beforehand, they got them to exercise for 20 minutes. And this was 20 minutes of, you know, moderate cycling. They they cited 60% and Theo to max. So you're working, like you're not going all out, but you're working pretty hard. You'd be feeling a burden during those 20 minutes for sure. Now, just the 20 minutes of moderate cycling did significantly improve cognitive performance. It did not reverse it back to baseline. You know, for example, so reaction time dropped about 14% when you were sleep deprived for 24 hours, exercising for 20 minutes reduced it to about a 7% drop from rest at state. So cut about half of the damage. Exactly. Exactly. So it's you're all like, you know, everyone kind of knows, you're not going to get back to exactly where you were with you know

...