The Gut Health Podcast

Sleeping Smart for Optimal Health with Neurology Expert Cathy Goldstein, MD

• Kate Scarlata and Megan Riehl • Episode 9

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Sleep isn’t a luxury—it’s essential. In this episode, we’re exploring the critical connection between sleep, gut health and overall well-being, backed by cutting-edge research. Join us as we welcome Dr. Cathy Goldstein, a renowned professor of neurology at Michigan Medicine and an expert in sleep disorders. Ever wondered why melatonin supplements might not be the solution to insomnia? Dr. Goldstein is here to debunk that myth and highlight the transformative impact of behavioral and lifestyle changes on sleep quality. We’ll also delve into the fascinating links between mental health, sleep, meal timing, and digestion. Plus, you might be surprised to learn that gastroenterologists often detect sleep disorders first, thanks to the unexpected findings during routine colonoscopies. 

Discover the current science for treating obstructive sleep apnea and insomnia, with a deep dive into the effectiveness of Continuous Positive Airway Pressure (CPAP) and a specialized therapy called, Cognitive Behavioral Therapy for Insomnia (CBT-I). Dr. Goldstein explains the significance of sleep hygiene and the vital role that different sleep stages play in our cognitive function and overall well-being. Learn about the impact of circadian rhythms on gut health and sleep, and how late-night eating can wreak havoc on your quality of sleep.  

As we navigate through the fascinating relationship between nutrition and sleep, Dr. Goldstein highlights the potential of personalized dietary plans and surprising research regarding supplements and sleep quality. You'll also get practical advice on the limitations and best uses of wearable sleep tracking devices. No matter your age, this episode offers actionable tips to improve sleep at every stage of life. Don't miss this thought-provoking episode packed with expert advice and valuable information to optimize your sleep and overall health.

Read more:

The Role of Gut Microbiome in Sleep Quality and Health: Dietary Strategies for Microbiota Support


Effects of Diet on Sleep: A Narrative Review

Learn more about Kate and Dr. Riehl:

Website: www.katescarlata.com and www.drriehl.com
Instagram: @katescarlata @drriehl and @theguthealthpodcast

Order Kate and Dr. Riehl's book, Mind Your Gut: The Science-Based, Whole-body Guide to Living Well with IBS.

The information included in this podcast is not a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider before starting any new treatment or making changes to existing treatment.

Kate Scarlata:

Thank you. The Gut Health Podcast will empower you with a fascinating scientific connection between your brain, food and the gut. Come join us. We welcome you.

Dr. Megan Riehl:

Hello friends, and welcome to the Gut Health Podcast, where we talk about all things related to your gut and well-being. We are your hosts. I'm Dr Megan Riehl, a GI health psychologist.

Kate Scarlata:

And I'm Kate Scarlata, a GI dietitian. We have a very exciting podcast for you. Today. We are talking about sleep. We all need it and some of us are better at maximizing our sleep quality than others. Sleep also plays a key role in maintaining our physical and mental well-being. It can influence our hormone levels, mood, appetite and even our weight. And guess what? It profoundly affects our gut health.

Dr. Megan Riehl:

It's really fascinating, and as adults, we will spend an average of one-third of our life sleeping ideally depending on whatever life stage you're at and so we better try and do it as well as we can, Kate, and I like to say you know, buy the good sheets, make your bedroom a beautiful oasis.

Dr. Megan Riehl:

And today we have a true international rock star from the sleep world joining us. Dr Cathy Goldstein is a professor of neurology at the University of Michigan in the Sleep Disorders Center. She holds several leadership roles within and outside of the university, and if you wear a device that has some degree of sleep tracking, she has probably researched it. Because get this. Dr Goldstein's research uses those sleep tracking devices and mathematical modeling to assess sleep patterns and circadian rhythms in the real world, our day-to-day settings, and this informs research in the area of women's reproductive health, MS and gastrointestinal conditions. She is a true powerhouse educator across a variety of learners, including physicians, peers in the sleep space, University of Michigan, athletes and coaches, and you might even recognize her from features on CNN, with the New York Times and Time. Dr Goldstein, my dear friend, welcome.

Dr. Cathy Goldstein:

Thank you so much for having me both of you.

Kate Scarlata:

We are so excited, so we always start our podcast with a little myth busting, because there's a lot of pseudoscience out there. So what myth bust would you like to share with our audience pertaining to health and sleep?

Dr. Cathy Goldstein:

Yeah, I think one of the biggest ones that I probably encounter every day in clinic at every family event is that melatonin helps with insomnia, and that is probably the biggest myth that we try and fight in the sleep world. Insomnia has never been shown to be due to a melatonin deficiency. Melatonin is something our bodies secrete. It's our signal that it's nighttime and it's time for things to wind down and go into that quiescent mode. So taking melatonin exogenously is really, really not the cure-all for insomnia.

Dr. Cathy Goldstein:

It's great for things like jet lag or, if you're a severe, severe night owl, something we call delayed sleep-wake-based disorder, but insomnia is really due to problems that we can have behavioral interventions for. So we do things like we mistime our sleep, we go to bed too early, we reduce our sleep hunger or what we call our homeostatic sleep drive, by sleeping in and napping. We have a lot of maladaptive thoughts that arise when we start being unable to sleep. So we catastrophize the consequences of a night of poor sleep, and then, on top of that, we added behaviors like well, if this is going to be such a disaster, I'd better spend a long time in bed trying to sleep. And then we form an association with the bed and wakefulness. We use substances that interfere with our sleep, like caffeine and alcohol. So there's so many other targets, but we really really like that idea of oh, if melatonin is what's secreted when you're falling asleep, I need to take melatonin from Target or CVS. So I hope everybody can take that home and kind of revisit their relationship with melatonin.

Dr. Megan Riehl:

We'll certainly dive into that, and so I guess we're starting our episode today with information that is not uncommon on The Gut Health Podcast, where a pill is probably not going to be the end-all, be-all to your problem and we probably have to work as a team to get things optimized 100%.

Dr. Cathy Goldstein:

I think we have a lot of overlap in our areas there.

Dr. Megan Riehl:

Well, let's dive into that overlap. So your husband just happens to be a gastroenterologist at the University of Michigan, and so I'm sure there's some fascinating dinner table conversations regarding the intersection of neurology and gastroenterology. Give us a little insight into the Hiatt-Goldstein dinner table combo.

Dr. Cathy Goldstein:

Yeah, and I wish I could tell you this is something very esoteric and intellectual, but I think anyone on your podcast who's listening that there's two healthcare providers usually sit down at the table. It's like what's the weirdest thing you've seen today. But things that we've kind of found more interesting and systematically have come up is a lot of times.

Dr. Cathy Goldstein:

Our gastroenterologists are folks that detect patients' obstructive sleep apnea. So people are really good about their preventative healthcare or primary care docs will get folks in at midlife for their colonoscopy and they get that sedation and they hear snoring pauses in breathing. People are dropping their oxygen and they hear snoring pauses in breathing. People are dropping their oxygen and so our GI docs actually often refer these folks to the sleep clinic. So sometimes people don't even have any symptoms and they end up because of the colonoscopy finding. So that's kind of wild. And then we've both just always been very impressed with how mental health bleeds in to both clinical areas, so so much. And mental health impacts all systems in our body and can overlap with any chronic health disorder. But we've both been so impressed how it shows up in GI symptoms and sleep symptoms even with larger magnitude than anywhere else.

Dr. Megan Riehl:

Early in my career I did some pilot research with Cathy and kind of that insight and I found it to be fascinating as a GI psychologist that so many of my patients were suffering with sleep difficulties. So yes, it certainly bleeds over and our way in which we help people manage these comorbidities really requires that dream team. And we have a guest. Dr Goldstein's cat has joined the podcast and we love animals around The Gut Health Podcast. So welcome to... I can't remember that one's name.

Dr. Cathy Goldstein:

Yeah, and that one actually has inflammatory bowel disease from the vet. So here we go. It comes full circle.

Kate Scarlata:

There we go, there we go. That is so funny. There are so many factors that impact sleep. What are some of the top things you see in your practice that are really affecting people in their sleep patterns?

Dr. Cathy Goldstein:

The biggest thing that we take care of. The most common thing that presents to sleep clinic is obstructive sleep apnea. So obstructive sleep apnea is a disorder where there's repetitive closure of the upper airway during sleep, at the level of the back of the throat. When this happens during sleep, your lungs don't fill with air, your oxygen levels drop and your brain wakes up and tells you to breathe, and so patients come in and they're waking up a lot. They feel sleepy during the day. But we also know that this disorder can increase the risk of high blood pressure, diabetes, heart disease and worsens GERD symptoms, and so it's really, really a significant problem, and we used to think this was a problem in obese middle-aged men. We now know it could be in women, thin people, children, and I still get surprised every week when somebody I thought had insomnia or even narcolepsy. Actually it's all due to obstructive sleep apnea, and CPAP has gotten a bad rap, unfortunately, over the years. But CPAP truly is the best treatment for obstructive sleep apnea, and a lot of myths exist among our patients Like, for example, you're giving me the CPAP machine. That's just covering up the problem. Why don't we just get to the bottom of this and do surgery and take out my big tonsils and my big uvula, and the reason that that doesn't work is keeping your airway open at night is a really complex problem and it's not just having big tonsils or a big tongue or a big uvula, but it's also our brains control keeping our airway open. It's also the muscles in our airway, and so we have really complicated conversations in clinic about this and with education we really are able to move the needle on getting people to use CPAP to treat their obstructive sleep apnea and once that benefit and symptoms is seen that improvement in sleep consolidation at night, that improvement in alertness during the day, reduction in GERD symptoms, drops in blood pressure in our hypertensive patients we really see people engage with their treatment and that's huge for us.

Dr. Cathy Goldstein:

The other biggest condition that we see in clinic is insomnia, and the type of insomnia that is the most common is something called psychophysiological insomnia, which is a mouthful, but it's a really nice explanation of what it is. So for some reason, someone will start developing difficulty sleeping, or they've always been predisposed to being a light sleeper and then they start developing these maladaptive habits and behaviors that start to perpetuate their mind going and, going and going at night, or what we call cognitive hyperarousal. So to cope with the difficulty sleeping, people will spend extensive time in bed. They'll develop these really complex wind down routines where they start worrying about sleep while they're like out to dinner. What am I going to do when I get home? I need to get the check so I can start my bedtime process. And this is really what perpetuates that cognitive hyper arousal. This I'm tired, but I'm wired.

Dr. Cathy Goldstein:

And then these individuals spend so much time trying to sleep that they start to associate the bed with wakefulness and it's just a complete downward spiral. And the best treatment for this is from our behavioral sleep psychologist and it's called Cognitive Behavioral Therapy for Insomnia and it works better than any sleeping pill on earth. That's not just an opinion, there's actually trials and it's a really important treatment that I think any patients with insomnia can benefit from. And again, it's kind of breaking some of these habits. So even if you're somebody who has insomnia, but not to the extent you presented to clinic, like if you have insomnia, don't start going to bed earlier. If you have insomnia, don't sleep in on the weekends so you can catch up on sleep. These are things that perpetuate the problem and there's a lot of myths out there and perceptions regarding how to improve insomnia.

Dr. Megan Riehl:

Yeah, as a health psychologist, there are some basics of things that I offer, and one of the first things I start with is just getting an idea of what are you doing of things that I offer. And one of the first things I start with is just getting an idea of what are you doing in bed. I always highlight that the bed is for sleep and sex. That's it. It's not our dinner table, it's not our desk for work. It's really only supposed to be for those two things. And to your point that there becomes this anticipatory anxiety of I've got to get to sleep. So I'm curious just basics, because I always find this, I remind myself this sometimes, even if I'm kind of having a difficult time with a couple nights of sleep what is a sleep cycle? How many do we go through in a night and when do we get our most restorative sleep?

Dr. Cathy Goldstein:

So this is a fascinating topic. So sleep cycles and sleep cycling refers to how we progress through the different types of sleep throughout the course of a night and we enter our sleep through non-REM stage one sleep, which is very light sleep, and then you go into non-REM2, and that's a bit deeper. We start seeing synchronized activity in different parts of the brain that we can pick up with our brainwave measurement or EEG. And then we go into non-REM3 sleep, and a lot of people have actually heard of this, but not by that name. They've heard of this as slow wave sleep or deep sleep, and this is the type of sleep that you can think about. It's the metabolism of your wakefulness. That's what's the marker of how we get rid of that pressure of being awake. That grogginess that ensues is our non-REM, slow-wave sleep.

Dr. Cathy Goldstein:

And then we go into REM, and the crazy thing about REM is that REM looks entirely different than the other stages. So you lose that synchrony of the brainwaves. It kind of looks like wakefulness. Your eyes are going up and down we can actually see it in our sleep studies and so you have a very active brain, active eyes, but the rest of your muscles are paralyzed, except for your breathing muscles. So it's fascinating and we don't fully understand why we have these different stages. It's just something that has been observed. Once we started recording sleep and we parsed them out into these different names. But clearly they all have different purposes. So when people ask us, usually because they've tried to measure their sleep stages that they're wearable.

Dr. Cathy Goldstein:

I'm not getting this stage. I'm not getting that stage. Is that why?

Dr. Cathy Goldstein:

my memory is falling apart. I tell people all sleep stages are required to be restored and alert and cognitively intact. You can't just have one or the other and also we can't preferentially really increase different sleep stages. There have been some gadgets on the market to increase slow waves and also we can't preferentially really increase different sleep stages. There have been some gadgets on the market to increase slow waves, but there are these bulky headbands. I would think in the end they disrupt your sleep overall more than they help. So it's really making sure you're getting appropriate sleep as a whole and not pressuring yourself to hit one sleep stage or the other.

Kate Scarlata:

All right. So before I get started with my next question, I just want you to describe what a CPAP machine is, because some of our listeners absolutely know what you're talking about. But I did want to have that like quick definition what is this machine? So that listeners can understand what you were talking about a moment ago.

Dr. Cathy Goldstein:

Absolutely so. CPAP stands for continuous positive airway pressure and it's a machine that I would say it's roughly the size of a shoebox. That positive airway pressure goes through a tube and the tube's about six feet long. It's flexible, it's made out of medical grade latex and then to a mask, and the masks either go into the nose, just over the nose, or over the nose and mouth, and we really rarely use the infamous Darth Vader masks that people often associate with CPAP and are concerned about using. We use much smaller, low profile masks. And then that air pressure prevents that airway collapse that we see in obstructive sleep apnea Snoring.

Dr. Cathy Goldstein:

A lot of times people are wondering well, where does snoring fit in this? Just because you snore doesn't mean you have obstructive sleep apnea. But most people with obstructive sleep apnea will snore and snoring is a reflection that the airway is so relaxed that it's vibrating and it makes that snore sound. And the CPAP machine will get rid of that as well. So bed partners tend to love CPAP. It makes like a little quiet, white noise, which is much better than snoring, choking and gasping at night.

Kate Scarlata:

I think so. For sure. Okay, let's dive deeper into the impact of sleep on our gut and its health. Can you speak to how our gut microbiome may play a factor into sleep and vice versa?

Dr. Cathy Goldstein:

So I think kind of the first thing to think about when we think about sleep and GI health in general is what's been found in the last few years is that sleep disturbance are really really common among patients who have GI disorders. So if you look at IBS in particular, 72% if you survey them have poor quality sleep in general. That's really really high. Sleep disturbances are common across adults in general. But 72% we don't even hear numbers like that in medicine with anything 50% have insomnia and 40% take sleep aids. So a really large percentage of this population is struggling with their sleep and we know when they have insomnia, when they're sleep deprived or when they're sleeping at the wrong time or have circadian misalignment, which means a mismatch between when your biological clock wants to sleep and when you're actually getting sleep. So think of like a night shift worker or somebody who has a naturally very late clock, who's a night owl but has to get up very early for work. These are ways you can disrupt your circadian clock and these worsen the expression of GI disorders. So this can worsen pain and symptoms in IBS. This can increase the risk of flares and IBD. So this is really critical.

Dr. Cathy Goldstein:

These disorders kind of impact each other, the gut itself, like the tissues of the gut. What's surprising is they actually have their own biological clock right. So our biological clock that for a long time we thought the machinery for that was in the brain only. Actually, almost all the cells in your body have that clock machinery. So things aren't just happening at random times of physiological processes and the cell processes. They're really really exquisitely timed.

Dr. Cathy Goldstein:

So, as you can imagine, if your gut has a natural clock, you do not want to be eating pizza at three in the morning. This is going to cause problems and we know that that's the case. And when you disrupt the clock by behaviors like that, you're not only disrupting your peripheral clock in your GI tract but you also can have misalignment of your central clock. So these things are very, very. We say the brain is kind of the conductor and this is a very complicated orchestra.

Dr. Cathy Goldstein:

The microbiome, again very circadian driven. So all those microbiome, all those organisms, those also have their own clock machinery and if the individual, the host where that microbiome lives, if they have circadian disruption. Again, think of things like night shift work, jet lag and potentially even what many of us do, which is something called social jet lag, where we go to bed later and wake up later on the weekends. That can all cause circadian disruption, and when the gut microbiome has circadian disruption, those organisms tend to move towards a more inflammatory profile, and so that could be one of the ways we see increased risk of all kinds of disease cardiovascular metabolic in people who have circadian disruption.

Kate Scarlata:

Yeah, it's really interesting because I've read about like bacterial metabolites, due to even dietary changes, may impact sleep patterns and that people with sleep disruption have different types of microbiomes that appear to be more dysbiotic. So we're really like starting to piece out some of this microbiome piece. And I think of my GI patients you know that maybe have the pizza, maybe not even at three o'clock, but maybe 730. And they have so much gas and bloating and triggering of their GI symptoms that certainly they don't feel very calm just to relax because they're fighting off a battle within. So there's that component as well, right?

Dr. Cathy Goldstein:

Absolutely and one of the biggest. And unfortunately as sleep providers we're not great at educating our patients on this. But a lot of times my patients will come to me and they'll say I moved my dinner up by two hours and my sleep has changed dramatically and so kind of even independent of that circadian clock and thinking of things at a molecular level, but just eating at that later time and then becoming recumbent. We find that if people move that earlier, at least four hours before bedtime at least and I've had when people go even earlier they get better effects. It really really can have an impact on sleep.

Kate Scarlata:

Yeah, I mean that makes sense, right, because our gut microbes are responding to food and they're responding to fasting, and so I think, in addition to calming the gut, you're also probably changing metabolite production at the time. Maybe that you're, you know, should be having some shut eye. So I can't wait for them to kind of dig this data out a little bit more into like clinical pearls. We're not really there yet, but it is really fascinating.

Dr. Cathy Goldstein:

Absolutely. And you know, with GERD one of the things that we've seen is that even if people don't have the symptom of acid reflux, gerd can disrupt your sleep. So they've done a lot of studies in GERD. They're far beyond in the GERD area than they are in the microbiome at this point and they looked at sleep overnight and all these different arousals from silent episodes of acid reflux. So that alone really, really should act as a precipitant for people to move those mealtimes up.

Dr. Megan Riehl:

Totally agree, we're thinking like people that have poor sleep may need to talk to a gastroenterologist, and then you know patients that are presenting to their gastroenterologist with some of these struggles, whether they be gastrointestinal or other ways in which they're feeling symptoms in their body. The path looks more holistically and sleep is really at the core here that it's hard to do anything well in our life, whether it be thinking, eating, participating in our day-to-day activities, if we're not sleeping well.

Dr. Cathy Goldstein:

Yeah, and what really you reminded me of just then when I'm thinking about the patients that you see and treat. Lack of sleep, sleep deprivation, is hyperalgesic. So if you are not getting enough sleep, you're experiencing pain in a more sensitive way, wherever that pain is coming from.

Dr. Megan Riehl:

So if it's in your muscles, if it's in your joints or if it's in your GI tract, that's a huge point to make for people that are struggling, and what I do think is really empowering is that we can optimize sleep right. We can work on this. It's just a matter of just the way in which we help people with gut issues recognize that it's oftentimes multifactorial. It's not just maybe an organic issue or a functional issue. Oftentimes there's a nutritional piece, there's a stress piece, there's a mental health component. So to that point, I talk with my patients a lot about the role of stress and anxiety on their overall health, but specifically, they're typically coming to me from a gut health perspective. So what are some of the from a gut health perspective? So what are some of the really important factors related to stress and mood on sleep that you talk with your patients about?

Dr. Cathy Goldstein:

Obviously with clinical diagnoses anxiety, depression we do see pretty profound sleep disruption. But if we kind of move a little bit more proximal to that and look at just kind of general life stressors, these obviously are going to impact the sleep. And the biggest thing we see if somebody is undergoing a stressful season, particularly if we're looking at sleep in midlife they can fall asleep okay, but they can't stay asleep. And we know it's very normal to wake up at night. Waking up like three times is normal. But what becomes abnormal here is the inability to fall back to sleep. And then it's nice and dark and quiet and every stressor concern, anxiety or worry comes out at this time and people lay in bed thinking about these things, trying to problem solve, worrying, and then that causes the association with bed and wakefulness and stress and it perpetuates insomnia. So the best thing to do when people find themselves in this situation is to get up out of bed, leave the bedroom and do something relaxing in dim light. Leave the bedroom and do something relaxing in dim light. I really find in general and this almost gets outside of the sleep world and more into the performance and productivity world that adults don't do a good job.

Dr. Cathy Goldstein:

Planning right. We get in the day, we open Outlook, we see what our calendar looks like and then we open our email and start putting out fires. No one has a broader plan for their month, their week and their day. So I really encourage people. People often ask me because I'm in the tech space. They're like what's your favorite sleep gadget? And I'm like it's an app called Evernote where I plan what I need to do and I can do journaling. I plan what I need to do and I can do journaling and that's what I would love to see people make part of their day. We always say good sleep starts in the morning and so it's really working to get these thoughts down, get these worries down and how you're going to deal with them. Think about what projects you have for the week, for this month, for this quarter. So you have a plan. So you're not making that plan at two in the morning when you can't return to sleep.

Dr. Megan Riehl:

Right, and this really, really does help. It's stress management. It's anxiety management.

Dr. Megan Riehl:

Whether you have an anxiety disorder or not, we all have day-to-day stressors and actually in our book, Mind Your Gut, we talk about a strategy called constructive worry. That is outlined you can check that out in our book. But just briefly, it speaks to your point of taking some time, a couple hours before getting into bed, to think about what are some of the stressors that I have going on, what are some of the fires that I want to put out, and in the wakeful hours of the daylight, maybe, being able to reach out for social support or to touch base with somebody, follow up things that we can't do in the middle of the night and we have more resources available to ourselves in our waking hours and you come up with some plans and strategies that then, when the little light in your brain goes off at 3 am, you're able to kind of go no, no, I thought about that problem, I thought about that stressor, I've got a solution for it and we're more likely to be able to fall back asleep.

Dr. Cathy Goldstein:

And we recommend the exact same thing. I'm so on board with that. I wish more people would do that.

Dr. Megan Riehl:

Yep, well, they will, now that they're listening.

Kate Scarlata:

And I have to say that I do that now because of writing the book with Dr Riehl. I am one of those people that wakes up and starts thinking about everything and then I get nervous that I'm going to forget the thing that I was just remembering. And if you do that pre-work before bed, two to three hours before, you can just knock those worries right off the table while you knock back to sleep.

Dr. Cathy Goldstein:

I also like a mindfulness practice to overlap with this too. Right, and I think one of the great things about mindfulness and combining it with something like scheduled worry or constructive worry is that you can give yourself permission in the middle of the night. That's just a thought about a stressor. I already dealt with that and I think that's because people have a lot of perceptions about meditation. And I'm not a Buddhist and how could I do this? I'm not a Zen person. I like my anxious thoughts. For me, that's not what mindfulness is about. It is about giving yourself permission to recognize that real. That's going on as just thoughts, and now you have an outlet to deal with them that is outside of the sleep period.

Dr. Megan Riehl:

So one more tip and trick that we can give to people tonight is that when you get into bed, notice your posture. Are you curling up into a ball with your hands clenched and your shoulders up by your ears? And that's how you're starting your sleep night. I always love people to think about starfish. Sleep starfish, where you open everything up, you pull your shoulders down, you open your hands wide, you give yourself the cognitive self-talk of I'm going to allow myself to let go of the stressors of the day, I'm going to relax my body. I'm going to notice how that feels, and so starting your night with relaxation will allow you to. Then, however, you get into your comfortable sleep position is fine, but you've made a conscious effort to activate that parasympathetic system, your body's relaxation response, which is going to cue you up for a better night of restful sleep.

Dr. Cathy Goldstein:

Absolutely.

Kate Scarlata:

I like that. I'm going to definitely starfish this evening. There you go, there you go. So as a GI dietitian, you know I like to think about how diet may play a role, and we've kind of broached this a little bit about timing. Any thoughts on just fiber eating, a nutritious diet, modifying healthy fats, that sort of thing. Is there any diet connections that you've read about as a sleep expert and what you recommend maybe to your patients?

Dr. Cathy Goldstein:

Yeah, the most we have is indirect at this point. We want people to have healthy diets in general so that being overweight or obese, which impacts your sleep, is less likely to be a problem. The timing is huge. Again, we don't know as much about the components, but the timing is huge. We do like for the evening meal to be a lighter meal but contain some protein and or fiber so that people can remain kind of full. Right, we don't want people. It's a balance between not having like actually physically full stomach and going to bed, but also not being hungry as well. One of the most interesting things we've seen about diet and sleep is that a ketotic diet can improve sleepiness, even in our patients with narcolepsy, which is amazing. So that you know, the ketotic diet has profound effects on the brain. They use it to treat epilepsy and it might be a target for disorders of sleepiness as well. And I even tell my patients and you know this is more anecdotal Everyone has a dip after lunch.

Kate Scarlata:

It's a physiological response, and so I tell all of my patients make sure your lunch isn't filled with carbohydrates and see how that improves, and we get a lot of benefits from that, looking at various diets and sleep, whether it be even narcolepsy or epilepsy, there are different, probably microbiome features in people with those conditions that may benefit more so from different types of diets too. So it's hard to give sort of a general one-size-fits-all with diet. Would you agree with that?

Dr. Cathy Goldstein:

Oh yeah, and we know so little at this point. We know as far as true data goes. I mean, I'm just working to get our patients to a more healthy diet in general, so that's oftentimes our biggest goal, because a lot of the people I take care of are quite obese. So we're looking to work with our nutritionists for both increasing that quality of the diet and then also reducing the caloric intake.

Dr. Megan Riehl:

Sounds good. One thing that pops into my mind again, kind of our dream team approach, of the importance of the physician, the registered dietician and the psychologist, is for our patients that have gut problems, avoiding food all day long, so that they can get their tasks done, so that they're trying to avoid the symptoms, the GI symptoms. And then to your point it's really counterproductive to have your largest meal at the end of the day, where sometimes people feel safe, like okay, I'm home, I'm not leaving again if I have urgency. But again we'll talk about one example or one demonstration that I'll give with patients and you can correct me if I have urgency. But again we'll talk about one example or one demonstration that I'll give with patients and you can correct me if I'm wrong, but I'll say okay.

Dr. Megan Riehl:

And then you go, lay down and think about the body. The body wants gravity to work with it and so you've put all of the calories of your day and you're laying down and it's harder to go through that digestive process. That's where we see people waking up with nausea and gas and bloating and GERD and these wild fluctuations, and when they're having bowel movements, and so again it becomes behavioral of moving those meals, spreading them out, but also so critically important to work with a dietician to find those foods that are gentle on your gut and that are going to get you back into that rhythm that will help with the circadian rhythms of both your gut and your brain.

Dr. Cathy Goldstein:

Yeah, the body is not equipped to handle food at night, it's just not. And then we've completely and remember, it takes so long for people to evolve, so we are not biologically evolved with how we live in this society, which is go, go, go during the day and then we're going to go home at night, we're going to relax in front of a screen and eat food. That's not what your body is made to do. Your body is made to live with a farmer. You should be eating when it's right outside, really primarily. That's when your largest amount of food intake should take place. That's when your body is best equipped. And they found, when you calorie control, people, even on the same diet, depending on when they time their food intake, the individuals who time it most with breakfast are going to lose more weight. But I understand why people definitely make those changes because of fear and that you know. That's something I should actually start asking my patients. Are you avoiding eating all day because of your IBS, eating at night, and that's what's causing your insomnia?

Dr. Cathy Goldstein:

And that's where there can really be a lot of collaboration in our field.

Kate Scarlata:

No, definitely, because if you can calm the gut, you'll sleep better. If you're sitting there wrangling with gas and bloating and abdominal pain and trying to get to sleep, it definitely can be a lot more challenging. I know you mentioned melatonin Not that beneficial, probably. Are there any supplements at all, or is it really lifestyle?

Dr. Cathy Goldstein:

Actually there was a very large meta-analysis looking at all the supplements that have been used in sleep valerian, melatonin, all of these things and none of them work. So really the only supplement so melatonin and circadian rhythm disorders, so jet lag, shift work disorder if you're a night, severe night owl. Really the only supplement is iron, and the only time we would use iron for sleep is if somebody has restless leg syndrome, because iron is a cofactor of dopamine. We think changes in dopamine transmission cause restless legs, people with restless legs. So that's the urge to move the legs in the evening and you can't settle down, can't fall asleep at night because of that. These patients have been found to have low central nervous system iron and so that's really it's very non-sexy. That's the only supplement that has really been identified over and over again to improve sleep, but it's in a certain context. Magnesium has some data. It might improve general sleep quality and it might improve restless leg syndrome as well, but it's pretty minimal.

Kate Scarlata:

Okay, so just to go back to the melatonin in those certain subsets of people that may benefit, how much is recommended?

Dr. Cathy Goldstein:

Again, it definitely depends on the context, but when we're using melatonin in a way that's an evidence base, what we're doing with the melatonin is we are trying to move the clock. We are not trying to knock people out. We are trying to move their biological clock earlier, typically with the use of melatonin. And so that requires that the melatonin is given at a very precise time and it has to be hours before your body's own melatonin starts. Otherwise it's like sitting in the ocean, like taking melatonin when your melatonin is being secreted does nothing.

Dr. Cathy Goldstein:

So, for example, say you're somebody who has severe delayed sleep, weight phase disorder. You sleep great from 4 am to noon, but that obviously doesn't work with your job. So I'm moving your biological clock earlier. I want to give you melatonin at least a few hours before your own melatonin secretion begins. And someone that falls asleep, well, at 4 am, their melatonin secretion begins at 2 am. But I don't want that melatonin to bleed into the wrong part of the clock. So we give half a milligram to one milligram. Have you guys ever seen half a milligram melatonin at the checkout shelf at Target? Never, nope. Three, five and ten. And we know that those amounts of melatonin increase the body's own melatonin during the daytime exponentially. So we just really don't like it.

Dr. Megan Riehl:

So the majority of people are taking this completely wrong.

Dr. Cathy Goldstein:

Way too much, yeah. And then the other thing there's all this variability. Like the melatonin may say three milligrams, but it could vary wildly the amount of melatonin that's actually included in that supplement, because these aren't regulated by the FDA. Once you take melatonin for a long time, you have down regulation of your melatonin receptors in your brain, so we really have no clue what's going on. And the problem with many things that I deal with and you guys deal with is the solutions are simple but they're not easy. And one of the best things you can do as a first step for your sleep, if you're struggling with sleep quality, insomnia at night, is to start waking up at the same time every single day, seven days a week. And that's really not as fun as melatonin that's in a cool bottle or comes with an app or you know so, but these are kind of the heart.

Dr. Cathy Goldstein:

Your body is biologically prepared to do what it's supposed to do. Right, we are biologically prepared to sleep. We've known in the history of sleep medicine is like actually missing one of these parts. Right, people have intact circadian rhythm and homeostatic sleep regulation. But our behaviors oftentimes are acting in opposition to that biology. Right, and it's not somebody's fault. The behaviors make sense. They're adaptive mechanisms, but we really have to strip those down to let your own biology work. And again, it's not a melatonin deficiency.

Kate Scarlata:

So interesting. I do want to just talk a little bit about the iron, okay, because I don't want the listeners to think, oh, run out, get an iron supplement, especially people that are challenged with constipation. I was going to say bind your right back up. Yes, so if they have restless leg, this is really a specific patient population you're discussing. How do they talk to their physician about the connection with iron? Like, what does the listener do that has restless leg that might say, hmm, what do I do with this?

Dr. Cathy Goldstein:

Yeah so, and even our primary care doctors are usually our first line of defense with this. They're all very well aware of this problem. So when we talk about restless legs, we talk about urge. So I have an urge to move the legs, so that's the U. It occurs at rest, so that's the R. It gets better with movement and it's more pronounced in the evening. Okay, so those are the symptoms you're looking at with restless leg syndrome. And when you go into the doctor you should have iron studies done. But it's important. They're low, but they're still. In. The normal range is when we supplement. So we supplement for ferritin levels of 75 and below and iron percent saturation of 20% and below, but above that you're not really going to absorb the iron, you're going to get constipated. There's some people that might even be predisposed to iron overload.

Kate Scarlata:

Okay, that's excellent. I wouldn't start iron without iron labs. Thank you, that's really important information.

Dr. Megan Riehl:

And I've got one more. We live in Ann Arbor, it's hot, we can pop into the dispensary for any and every ailment. What about the THC CBD products out there that people are swearing by? Are really getting them that good sleep?

Dr. Cathy Goldstein:

Yes, I mean, it's been a miracle for us. I'm surprised we have any patients anymore, because I hear it cures everything.

Dr. Cathy Goldstein:

But okay, here's what we know so far and I will tell you anecdotally a lot of my patients have good luck with them. Sleep is really hard because there's a very large placebo effect. But the placebo effect if it's getting you sleeping. There's a lot of push-pull with this, but what we know scientifically is that, yes, THC does seem to promote sleep. When we're looking at sleep as defined by EEG during the sleep study, the problem we see is that when people use THC-containing products too frequently and the cutoff seems to be about five times a week, it's almost like alcohol, where their insomnia starts getting worse, likely due to some type of withdrawal or dependency phenomenon. So if people do use it, yes, it might help your sleep. However, if you use it too much, it could have the opposite effect.

Dr. Megan Riehl:

Okay, so from the mouth of the world-renowned expert, with just another consideration yes, and also, yes, your body's made to sleep.

Dr. Cathy Goldstein:

Leverage your biology.

Dr. Megan Riehl:

Leverage your biology. I love that. So, all right, I want to talk a little bit about the wearables now and from this consumer space. There are lots of devices out there for sleep tracking, many coming to the market all the time, and actually you just had a review article in the journal Sleep that came out this year, and it highlights that the devices they give us opportunities opportunities being key for continuous, unobstructive and large-scale sleep monitoring in those of us in our kind of sleep environment, right at home in bed and it's fascinating what these things say, that they are tracking, like breathing rates, skin temperature, something called cardiac autonomic indices, which can include, like heart rate variability. So tell us what you found in your research about the wearable devices, because, again, people become desperate for sleep, and so, if it means shelling out a couple hundred dollars for a device, what are the pros, what are the cons?

Dr. Cathy Goldstein:

First thing. So these devices? One of my favorite people in the field they kind of the same thing. Yes, what you measure, you can improve. But just like a scale is not going to necessarily make you lose weight, neither is a wearable sleep tracker. And the other thing is that, because these are so ubiquitous, my goal is to make everybody like a wearables expert no gatekeeping. So I want all your listeners to understand how these work.

Dr. Cathy Goldstein:

So these devices, so my patient always comes in they say say, my watch doesn't get this much sleep. I'm like well, your watch actually doesn't measure sleep.

Dr. Megan Riehl:

They're like what are you talking about? Yes, it does it, says it it says it on my app.

Dr. Cathy Goldstein:

Yeah, these devices measure cardiac activity and they measure motion, measure cardiac activity and they measure motion and because we know what happens to your cardiac activity and your motion during sleep in a normal person, in a normal setting, that cardiac activity and that motion activity is then modeled by algorithms to determine when you're asleep or when you're awake. So, as you can imagine, this is not something that's going to work well in certain patient groups. We don't know how these work in people with pacemakers, afib, sleep apnea probably affects the performance of these devices and we really have to make sure we know what we're measuring here, which we're measuring sleep. So sleep is coming from the brain. We're measuring sleep in the periphery. We're measuring, kind of, the cardiac emotion output of sleep. So one of the most important things in sleep disorders, right, is the mismatch between the intent to sleep and the actual sleep. So if you are someone who sleeps seven hours, we have two patients that sleep seven hours. One person goes to bed at 11 pm, gets up at 6 am, one person goes to bed at 9 pm and gets up at 6 am. The difference between those patients is clinical insomnia now and they're getting the exact amount of sleep and that is the importance of the intent to sleep. And what do these devices not measure? The intent to sleep.

Dr. Cathy Goldstein:

So I find these are very limited in the exact population that wants to use them, which is our insomnia patients. And the other problem is that they misclassify non-moving wakefulness as sleep too. They have a tendency to do that because emotion is part of the input and also our heart rate drops when we're at rest. So currently and this isn't something humans used to do we flank both the bedtime and wake time with these and, particularly at bedtime, very long periods of non-moving wakefulness because we're watching Netflix, we're scrolling through our phones and again, that device has no idea if you're trying to sleep or not. Dropping heart rates, no motion, that's sleep. So we have to be very, very careful about what we're pulling from these devices and they cannot tell you how well you're sleeping or if you're happy with your sleep.

Dr. Cathy Goldstein:

So this is how I recommend they're being used, because you're going to say this is like your thing, that's made your career, and you're telling people. So the only time I recommend that people use these for their sleep is you really want to make sure you're going to make a change based on it. Like I'm not feeling well, I wonder if I'm devoting enough time to sleep. That's a great thing that you can pick up on these devices because the device, like I said, it thinks sometimes non-moving wakefulness is sleep. So if you're consistently six hours on that device, you're probably way less right. So if you're somebody who thinks they might need to extend their sleep time, that's a great way to use these devices. Also, if you want to do some what we call end-of-one studies, how does alcohol affect my sleep? How does exercise affect my sleep? How do dietary changes affect my sleep? You comparing you to you, not the average percentage of REM sleep by a 30-year-old male, right you comparing you to you?

Dr. Cathy Goldstein:

The problem with these devices and some of the patients that tend to use them who have insomnia they can worsen anxiety, worsen insomnia.

Dr. Cathy Goldstein:

They've even coined a name for it, called orthosomnia now, where people are relying more on what the device is telling them about their sleep than how they actually feel.

Dr. Cathy Goldstein:

And then the other thing sorry, I could talk about this forever I want people to keep in mind because one of the biggest things that people get upset about when they're looking at their data isn't that they're getting this many hours of sleep. It's that sleep stage breakdown. Sleep stages are EEG or brainwave constructs. We actually didn't even come up with the sleep stages until we were able to measure brainwaves during sleep. Right, they're a complete product of that. So, even though it could end up being something that's incredibly valuable the prediction of sleep stages because we know there's different cardiac autonomic changes during sleep stages and that's how your Apple Launcher, fitbit, is trying to predict them and that might end up being a really relevant thing but at this point we don't understand the relevance of it and I cannot preferentially increase your day-to-day REM sleep. So that is not a good use of these devices and people really want to look at them for that. They really want to hit this certain target and it's just not. It's not a good use of your time.

Kate Scarlata:

So interesting. Orthosomnia Is that what you said? Orthosomnia, yeah.

Dr. Megan Riehl:

Well, and you know I'm thinking about our orthorexia population that becomes just obsessed with health and eating and health, you know. And so again, I can see a big overlap here of having some tangible device that, like you said, you're paying more attention to the device than actually asking yourself how am I feeling? Do I wake up, feeling rested? Am I sleepy through the day? Am I moving my body? All of these kind of indicators of health.

Dr. Cathy Goldstein:

And people will completely ignore those things but will be fixated on the fact that my device says I get 10% of REM every night and I just don't know what that means yeah, there's some health disparities too for some of these products, and research too.

Dr. Megan Riehl:

I just want to mention that too.

Dr. Cathy Goldstein:

This is like a huge thing for me. Right now there is a millionaire no, he's probably a billionaire and one of his big things is sleep and he put out a sleep routine and I love any sleep in the media. Anything that makes people think about sleep I'm happy about, but there's a lot of people that can't. He recommends his last meal takes place at 11 AM. No stressful substances, but also no stressful environments at all in the hours leading up to bed. I don't need a fancy cooling mattress. We do not want sleep and healthy diet to be luxury items. These are things that should be equitably available to all people, and sleep is just not a luxury item, and that makes me so upset with when people think they need a gadget or a particular mattress to have good sleep. I think that's like the worst message that we can send. We want everyone to have good sleep, especially our most vulnerable populations.

Kate Scarlata:

Yeah, wow, I also think you know, just to Megan's point and to your point as well, just the whole relying on devices, relying on special things, really moves you away from just listening to your own body cueing in and that is so vital with nutrition, sensations of being full versus overeating, feeling restful and feeling less anxious, and all those positive things that you can just tune into without requiring special products. Yeah, 100%. So I just want to talk a little bit about just sleep and sleep through the lifespan and you know I love to talk about the perimenopausal, menopausal woman with hot flashes, but there's so many things that can impact our sleep, from being a young parent to, you know, stressful sandwiching between young kids and older parents. What are some tricks for different lifestyle phases?

Dr. Cathy Goldstein:

I love this question so much, and no one has ever asked me this on a podcast. So I think this is a great way that we don't typically think about sleep interventions, because we kind of think of, like pediatric people are over here, the adult people are over here. All these things are good for sleep, but I do think, like you said, given your life stage, we can target different things to focus on. When you think about adolescence, it's actually a really interesting time for sleep really interesting.

Dr. Cathy Goldstein:

So for your listeners that have teenagers and they're just going through this right now.

Dr. Cathy Goldstein:

So when kids get through puberty there's a phase delay in the circadian clock.

Dr. Cathy Goldstein:

So they biologically it's not that just that they I mean they also do want to be a whole night talking to their friends and playing video games et cetera but they biologically also become later. So I think a great sleep intervention to focus on in adolescence is really that avoidance of light in the evening time when we know that light at that time can push the clock later. And we're all pretty savvy right now about understanding the role of screens, making sure that we're cutting off screens, which a lot of times is not really possible. But all of our ambient light is also blue enriched at this point right now because we have LED lights right. So I think teenagers are great to put these orange, blue blocking lenses on. You can get them on Amazon. We use the UVex Skyper ones in research and putting these on a few hours before bedtime, particularly because your teenager's homework is going to be on a computer, really can help mitigate that biological phase delay in adolescence and also making sure they're getting lots of morning light.

Dr. Cathy Goldstein:

I have two sons.

Dr. Cathy Goldstein:

They like to be in this cave-like environment, and so they just love me because, if it's, light outside, I'm opening all the blinds, we're turning the lights on and then vice versa, once the sun goes down, I'm with my dimmer switches going around the house, and so that population is really, really important to take a light as a target. Love that. One of my favorite groups to deal with sleep is individuals who have kind of just entered the workforce. So they're usually still super healthy, but they have really bad habits, and their worst habit with sleep is they have that social jet lag. So they can still kind of tolerate some sleep deprivation. So they're waking up really early during the work week. Weekend comes around they start staying up till 3 am and sleeping in, and then on Sunday night it's essentially like we've flown from LA to New York.

Dr. Megan Riehl:

Sunday Scaries.

Dr. Cathy Goldstein:

Sunday Scaries. They literally talk about it on reality shows in this age group and part of the Sunday Scaries is because you know you're going to have insomnia because you've delayed your body clock and now you're going to try and go to bed at 11 in anticipation of that 6am wake up time. So my biggest recommendation for that group to focus on is, on the weekends, waking up no later than two hours later than your workday wake time. So that's kind of our cutoff for social jet lag. And if you're tired, take a nap in the middle of the day. That won't disrupt your circadian rhythm as much. But I always am recommending that with that group.

Dr. Megan Riehl:

How long can your nap be?

Dr. Cathy Goldstein:

Oh, 30, 45 minutes.

Kate Scarlata:

That's okay, that's okay, that's perfect Midlife.

Dr. Cathy Goldstein:

What I see come up is what we talked about a lot at the beginning of this podcast that tired but wired, it's quiet, it's dark. So I'm going to think about what I need to bring in for my kids' school, the project I have to do for work, et cetera, et cetera, and for that group I think that's scheduled, and what did you guys call it? Constructive worry or strategic worry? Scheduled, constructive worry is huge, and this is also a period of time where people start getting so, so busy in the evenings, and what I hear from a lot of my parents with younger school-age kids, even teenagers, teenagers is that nighttime is the only time I get to myself, right? So what happens?

Dr. Cathy Goldstein:

You take a population that I mean perimenopause can start in your late 30s, 40s, right? So you take this population that might already be having some biological changes that are going to predispose to insomnia. They want to stay up late so they can have their time. So they watch Netflix on the couch and proceed to doze off. Then they go to bed and they can't sleep, and I see this so much. So what I would love for self-care, instead of staying up late and dozing off in the couch, is for people in midlife to really start thinking about intentional bedtime routines instead of just dozing off. When they doze off and I know we have to do a lot of kind of pro cons because people say they love this time I'm like I promise you're going to be more productive the next day. I'm giving you back time by having you have a planned bedtime and going to bed earlier instead of dozing off on the couch. I think dozing off on the couch and a regular wake up times in the morning are two of the worst sleep habits that we have.

Dr. Megan Riehl:

Hi, it's me. I'm the problem. It's me. I just self-imposed a 10:30 bedtime two weeks ago. Because I wasn't dozing on the couch but I was going into my bed and I was not constructively, I was just scrolling away.

Kate Scarlata:

You were winging it.

Dr. Megan Riehl:

Yep, I would find okay, it's 11, 11:30. And I'm like this is not my bedtime, I can't be going to bed. Who am I? What am I thinking? So us in the field, we have to do these things too. As providers, we caregivers, we have to take a look sometimes. And you know what, I'm all the better for it. 10:30. I love it.

Dr. Cathy Goldstein:

That makes me so happy. And then I think about as we get older. So you know, you're getting older, you can focus more on sleep, but as we age, sleep can become a problem. You can focus more on sleep, but as we age, sleep can become a problem. So as we get older, we're dealing with menopause in women, we're dealing with health conditions that can disrupt the sleep, but even just in general, the sleep becomes less deep, the sleep lightens and the sleep timing also becomes earlier, right, so people tend to fall asleep. Great.

Dr. Cathy Goldstein:

But they're getting up at four in the morning and we know that exercise is good for sleep in all people. But exercise has really good data in older individuals and improving the sleep, especially afternoon exercise, can increase that slow wave and deep sleep that gets less in amount as we age. And then the other thing I like to augment that afternoon exercise period with is an evening after dinner walk, because that light and activity can help our older patients from falling asleep too early, and so I think that's a great intervention in our older individuals to help with sleep time quality.

Kate Scarlata:

Hello, that's me.

Dr. Megan Riehl:

Well, and I don't know if you've seen on the internet, there's a woman that's professing about the fart walk, and so there we go. We'll tie that in that after eating, you know, before bed, getting out, moving your body, getting out your toots it's a healthy thing to do. Moving your body, getting out your toots, it's a healthy thing to do, yes, so you know, I think that's the true tie-in of gut health and sleep is, you know, our physical activity and letting our body, you know, naturally release its gases so that you can get your Zs.

Kate Scarlata:

Exactly and not release it in bed.

Dr. Cathy Goldstein:

I think we know the name of your next book, ladies, and I'm excited to get your help with that Exactly and not release it in bed. I think we know the name of your next book, ladies, and I'm excited to be able to help with that.

Dr. Megan Riehl:

We have a new co-author, Kate. I love it, Cathy. We have learned so much from your expertise today and as we wrap up this episode that we know our listeners are just going to love and learn so much. We like to ask our guests the following question. So, Dr. Goldstein, what is something that you prioritize when it comes to your own overall health and wellness?

Kate Scarlata:

I think she's going to say sleep.

Dr. Cathy Goldstein:

Botox! Botox! No, I am a huge sleeper. I'm a nine-hour sleeper at night. But probably the biggest thing for me is exercise. It's my coping mechanism for stress. I feel like I'm very sensitive to not having it. I tore my ACL and had surgeries and basically went bonkers after that surgery. So I have to move every single morning.

Dr. Megan Riehl:

Move. Allow yourself a good night of sleep.

Dr. Cathy Goldstein:

I move my body and not my face and not your face.

Dr. Megan Riehl:

That is my premise for self-care. Love that I love it, I love it. Well, thank you so much this was incredible.

Kate Scarlata:

I learned a lot and I know our listeners will definitely learn a lot. So thank you so much for coming on. We appreciate it. So to our listeners make sure you subscribe, follow and like The Gut Health Podcast. Your support means the world.

Dr. Megan Riehl:

Friends, thanks so much. Thank you for joining us as we grow this gut health community. We hope you enjoyed this episode and don't forget to subscribe, rate and leave us a comment. You can also follow us on social media at The Gut Health Podcast, where we'd love for you to share your thoughts, questions and experiences. Thanks for tuning in, friends.

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Kate Scarlata

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Megan Riehl

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