Podcast Transcript: Professor Adrian Williams on Everything You Wanted to Know About Sleep

This is an edited transcript of our podcast episode with Dr. Adrian Williams, the UK’s first Professor of Sleep Medicine. This was our first non-markets guest but our discussion on the impact of lack of sleep on decision making, how much we should sleep and tips for better sleeping made it highly relevant. While we have tried to make the transcript as accurate as possible, if you do notice any errors, let me know by email.

One of the Things in Life We All Can’t Get Enough Of…

Bilal Hafeez (00:01:24):

Now, in this episode, we decided to have our first non-markets related guest, Professor Adrian Williams. He’s the world’s leading authority on sleep. And I know that I, as well as our listeners, all have sleep issues. As for his background, Dr. Adrian Williams is the UK’s first Professor of Sleep Medicine. Adrian graduated from the University College London, and after a lectureship at the Cardiothoracic Institute Brompton Hospital in 1975, he took up an appointment at Harvard followed by an invitation to the University of California in 1977. In 1985, Professor Williams became tenured Professor of Medicine at UCLA and co-director of the UCLA Sleep Laboratory. In 1994, he returned to London where he established the sleep disorder center at Guy’s and St. Thomas’ NHS Foundation Trust. In addition to his role as Medical Director of The London Sleep Center, Holly Street, Professor Williams holds the UK’s first Chair in Sleep Medicine at King’s College, London, UK.

So, on to our conversation. Welcome to the podcasts, Adrian. Great to have you on. Over the years, we’ve had conversations and you’ve spoken at some events I’ve held. So, it’s always great speaking to you. And one of the reasons I wanted to get you onto our podcast is you’re actually the first kind of non-finance, non-economists that we’ve had on a Macro Hive podcast show. So normally we have finance people, economists. Recently, we had Sajid Javid, the former chancellor of the UK. So, it’s kind of people in that domain.

But I wanted to get you on because sleep is something that all of us in finance have, I wouldn’t say a problem with, but we have a relationship with. Whether it’s a good or bad relationship, kind of varies. And having worked on the trading floor in investment banks, you see people struggle with their sleep. They come in, they look tired, even though they may have tried to sleep, the famed eight hours and so on. And you can still see that sleep deprivation in different ways have real impacts on the way people are. And over the years, I’ve done a huge amount of traveling across continents. So, you really feel the effects of jet lag, which again goes back to sleep. So hence wanting to get you onto this podcast show.

Adrian Williams (00:03:36):

You’ve made very valid points over the importance of sleep. I’ve been through the whole history of the development of sleep as a medical area of interest to the point now that it is one of the three pillars of health, isn’t it? It would be said that diet, exercise, and sleep are the important things we need to pay attention to. As a sleep physician, it might not surprise you to hear me say it’s the other way around, sleep, exercise and diet. And sleep as I think the very crucial and particularly in regard to decision-making.

Adrian’s Background and Career Path

Bilal Hafeez (00:04:14):

Okay. Yeah. Actually, before we go into that, maybe I should ask you about your career background, because I do like to also my guests their origin story, so to speak. So, I suspect you did medicine at university, but did you know you were going to go into the field of sleep? I mean, tell us about the early days and how you’ve ended up where you are today.

Adrian Williams (00:04:34):

I love telling the story. Yes, I trained in London, in what is now UCL, then UCH and went into a specialty called chest medicine, because that was what I was interested in. I’ll come back to a small anecdote in a moment. So, I was going to be a pulmonologist, a chest physician. And part of that was to go to an institute to do a PhD. So, I went to the Brompton, which is a very well-established and famous institution, to work with a woman, a professor of pathology who was offered a chair at Harvard University. At the time, this was the very early 1970s when there were 150 full professors of medicine at Harvard, a most elevated thing in the whole of the US, and only six of them are women. So, they were quite anxious to get more of women and she was ideal. And so, she said, “I want to bring my team.”

And so, I went out with her and a few other people to Harvard, and then we set about research projects, which was de rigueur, and one of the ones I was given was to look at was sudden infant death syndrome or cot death. And in that study, we established it as a syndrome, meaning medically is there are more than one cause – many causes or some. Then we established that two thirds of the infants that died had a breathing problem. And that was sleep apnea, which is the now the common condition we think about in adults.

And there were some infants that didn’t succumb to that. They were called “near miss.” And I just wondered whether those who would go on to develop what we would then begin to appreciate as adult sleep apnea. And then at the same time, I was asked to go to California. People were recruited from Harvard often. And so I went off to California with the idea that maybe sleep apnea, this problem was actually quite significant. That was when people were beginning to talk about it. So, this is now the mid-1970s.

Bilal Hafeez (00:06:59):

And as you said, at that time, there was some interest in sleep apnea, but it was by no means an established field.

Adrian Williams (00:07:07):

No, absolutely. Yes, there was no training for people in medicine. And even though sleep had been of some interest in general, it was mostly of a psychological aspect, dreaming and other things, rather than as a physical disturbance. But the identification of sleep apnea, stop breathing as a problem, drove the sleep field forward. So, I happened to be part of that early development in the States.

Now, I’ll just come back to an anecdote going back to my time at the Brompton. When I joined this wonderful woman’s team, she was called Lynn Reed, she said, “Adrian, the French have been talking about doing tracheostomies in patients who have breathing problems at night.” And so, I took the idea to the other senior consultants at this very established hospital and I said, “Professor Reed is suggesting I look at this thing that the French are calling sleep apnea.” And what I heard from these rather elderly, but very established physicians was, “Ah, the French.” So, I didn’t take that on then.

But anyway, I got to California and took on the idea of sleep apnea as an issue. And then in the US, it became de rigueur that you had to understand sleep in a much broader perspective, which would be all the issues around lack of sleep – sleeping, insomnia – and other things that cause people problems – sleep walking and such.

So, it’s a whole range of issues. Again, I’ll probably start at my history in a moment. But I went from being a chest physician to the States, to then automatically becoming an intensive care doctor, because that’s what chest doctors did in the States, and then becoming a sleep doctor, which is a rather nice way of ending a career. I’ve been doing it for a long time, but it is a gentler form of medicine. If I’m called in the middle of the night with an intense care problem, it would be quite serious. If I’m called in the middle of the night by somebody who’s not sleeping, I would probably say maybe an aspirin, but that’s too much tongue in cheek.

Bilal Hafeez (00:09:35):

Yeah, I understand. So you were in California and then what was your journey from there? Because you …

Adrian Williams (00:09:42):

Yes. So, I was there for 20 years and became a professor of medicine at UCLA, and then was recruited back to London in the mid-1990s to take over a unit, which was an intensive care unit, and at the same time, develop a Sleep Center at Guy’s and St. Thomas’, which is now actually the largest in Europe. At the time I joined, there was one other person. There are now 10 or more consultants in that center.

Bilal Hafeez (00:10:13):

Okay, great. So you really are one of the pioneers in this field, so it’s great to have you.

Adrian Williams (00:10:18):

Yes, a long enough time.

Why We Sleep

Bilal Hafeez (00:10:20):

Yeah. And before we talked about your history, we were just starting to talk about decision-making. And so you were saying that there’s a link between poor sleep and decision-making. So can you elaborate on that a bit more?

Adrian Williams (00:10:35):

Yes. So what does sleep do for us? First thing I would say is that every organism sleeps. And that’s literally everything down to micro-organisms and tiny animals and large animals. Therefore, it has to be conceived of as being important. And if it weren’t, then it would be a big mistake on the part of evolution. And one test of that question is of course, if it wasn’t important, there would be animals that didn’t sleep. And equally, if it’s not important, if you deprived animals or us of sleep, it wouldn’t make a difference. But that’s not the case. In the very early experiments done in Russia at the turn of the 20^th century, dogs were deprived of sleep for three or four days and died in half the time it would take if they were deprived of water. So sleep was clearly important for them. And the more recent experiments of rats in rats of course – deprive them of sleep and they die after two weeks. And so, there are those clear signals it is important.

For humans, the experiments that have been done were deprivations to a certain point. The longest sleep deprivation studies have been done in America – up to 10-and-a-half days of no sleep. People become impaired in a sleepy sort of way. But clearly, it has extended to the point of physical deaths. That would be an odd outcome for that sort of experiment. But coming back to the impact of lack of sleep, before any of those bad things might happen, the immediate effect is clearly sleepiness. One of the reasons that people say we sleep is to prevent sleepiness. Now, why would that be …

A small digression, but if you deprive [goats] of sleep (it has been done), you can then take a sample their cerebral spinal fluid, because they’re large enough to do that. And if you then inject it into well rested goats, those other goats would fall asleep. So that led to the concept that there’s something called “hypnotoxins” – something that accumulates when we’re awake, that need to be dissipated by sleep. And they’d become more accurately characterize subsequently. So, sleep is needed to get rid of stuff that we accumulate in wakefulness. So, sleepiness is one consequence of not sleeping.

Impact of Lack of Sleep on Decision-making

Adrian Williams (00:13:32):

The other consequence is in fact, an impairment of performance. And here, the parallel would be alcohol. Now this might seem like a strange thing to say, but if I had a graphic in front of me, I could show you and everyone what we all appreciate. The more alcohol we have, the more our performance declines. So you can do the same graphic with a lack of sleep.

And it would be the decline in performance matching that of being technically drunk after more than 16 hours of wakefulness. So it is that something accumulates in wakefulness that makes us ultimately impaired. Now, the other part of that story is of if we sleep for our usual seven, eight or nine hours, that allows us to have that fully 16 hours of reasonable performance. But if we don’t have that adequate amount of prior sleep, then our ability to maintain very active, clear wakefulness has been impaired.

And I think you would particularly know the story of a study done with Google’s data. If you ask Google what questions are people asking over the period, they can tell you. And there was a study done over a six-year period of questions asked with moral import (questions with moral import would be like questions about death while questions without moral import would be about sports or things).

They found that the day after daylight’s savings time, that with one hour’s less sleep, there was statistically highly significant change in the way that people asked questions. There were much less moral questions being asked. So, there’s an impact on the way that people behave, as well as their capacity to do things properly and quickly with lack of sleep, which is quite separate from all the physical things that doctors tend to think about.

Bilal Hafeez (00:15:56):

Okay. Yeah, understood. Yeah. So many ways, lack of sleep, as you said, there’s parallels to being drunk. And so when we think of the ability for people to make decisions or act when they’re under the influence, you could expect to see something similar when people are deprived of sleep as well.

Adrian Williams (00:16:15):

Yes. That a fair summary. Actually, there are thoughts around your sleeping and you drunkenness if you like, or the lack of sleep. And of course, we probably won’t need to get into this, but how do you sort of measure that in terms of people driving? Which, that’s a new area, but people are interested in trying to do that.

Types of Sleep Non-REM and REM

Bilal Hafeez (00:16:41):

Yeah. And actually, if we kind of think a bit more about just some of the fundamentals of sleeping, so what happens while we’re sleeping? People, our audience who are probably familiar with REM sleep, so rapid eye movement sleep, and non-REM sleep. I mean, so what’s kind of happening to us while we’re sleeping?

Adrian Williams (00:17:00):

So sleep isn’t a uniform state, and you’re rightly said there are two types of sleep. One, non-rapid eye movement, and the other rapid eye movement. And they happen in a very organized way. So we fall asleep and then pass into light non-REM sleep and then into deep non-REM sleep. And that is the important restorative sleep – the sleep that repairs the body, if you like. And then within 90 minutes, and with remarkable precision, 90 to 100 minutes, we jump into REM sleep, rapid eye movements sleep, in which it is that most dreaming occurs. Not all dreaming, but most. And the difference that’s seen in the sleep study is quite obvious. The brainwave pattern slows very much during non-REM sleep – it’s actually called slow wave sleep. But in REM sleep, it’s very hard to distinguish it from being awake in terms of the brainwaves. So it is called active sleep. And then in animals, that was the first phrase.

So, the brain is active in REM sleep, and it is resting in non-REM sleep. But the other feature of REM sleep, which maybe your audience won’t know, is that the body is physically paralyzed in REM sleep to stop us acting out our dreams. And that’s one of the ways you can actually make a determination that is one is not awake, because the EEG, the brain waves are sometimes difficult. Anyway, this pattern, this cycle goes on the whole night. We spend most of the first third of the night in restorative sleep, non-REM sleep, and most of the last third of the night in REM sleep, dreaming sleep.

Now I anticipate another question. If non-REM sleep is restorative, what is REM sleep therefore? And the best answer at the moment is that it’s about memory. You can sense a hesitation in my voice because some memory issues go on in non-REM sleep, but it is perhaps around REM sleep. And I might quote someone I admire very much of DNA fame, Watson and Crick fame. Crick went off to San Diego to become a person interested in sleep (of all things). And he thought that the REM sleep was the reorganization of memory, getting rid of stuff. In his book, it’s called “the amazing hypothesis.”

Bilal Hafeez (00:19:45):

And what happens if you cut your sleep so that you just have the non- REM, the restorative part, and you kind of don’t have the REM side of it? So you kind of just have the first third say. I mean, is there any kind of consequence of that, or just, how do you think about that?

Adrian Williams (00:20:00):

Yes, indeed. No, you make a very good point and both types of sleep are important. If I jump back for literary 10 seconds to say that animals deprived of only REM sleep die as well. So it’s still important. And it is around perhaps the reorganization, the memory, but things are different.

And it’s very important because if you think about our children who tend quite naturally to have a later sleep time as they go into the teenage years, it’s the way the body clock naturally changes. And yet we expect them to go to sleep still at 8:00 or 9:00 PM and get up at 7:00 or earlier. And yet they’re not getting to sleep until 11:00. And we’re waking them still at 7:00. So what are they missing out on but their REM sleep? We’re changing the way that their brain is able to consolidate things, perhaps changing their attitudes. I mean, again, you sense in my tone is not quite certain, but certainly the children in that phase of schooling are sometimes put under enormous stress, which has led in the US of course, to later school times. Why would you force a child to get up earlier than they would want to get up?

Bilal Hafeez (00:21:26):

Okay. Yeah, that’s an interesting point. So, in some ways we’re kind of systematically depriving older children off their REM sleep. I mean, it’s a bit of a generalization, but …

Adrian Williams (00:21:36):

Yes, that would be fair to say. And maybe bankers too. I mean, if you have to get up at 5:00 or whatever, what sleep are you missing? Apart from just having less sleep, which has its own statistical generic effect on performance? Specifics about which bit of performance, it’s all quite interesting.

How Much Should We Sleep?

Bilal Hafeez (00:21:57):

Okay. And, this kind of also leads onto the question of how much sleep should one get. I mean, one often hears eight hours is how much sleep you should get. I mean, how do you approach that question? I’m sure you get asked this a lot.

Adrian Williams (00:22:09):

No, it’s not as easy to answer. It’s genetically determined. I guess that could be an answer for everything. In families, people tend to sleep the same amount, but the range is indeed from about six to 10 hours. The average is eight hours and our general range of seven to nine hours, but it is genetically determined and you can’t actually change that. So sadly, perhaps for those that need nine hours, that requirement on average is eight hours. But remembering there’s a range of seven to nine and that’s different for children but essentially we’re talking about them. It’s more for them.

And I guess another link to that is, do we need less sleep as we get older? And that’s not the case. In fact, even though elderly people might sleep less at night just because sleep is less easy to maintain, and children go to sleep and you can’t wake them – but older people wake rather more frequently and then make up for that with a daytime nap. But I stress, it’s still the same-24 hour requirement of sleep. There’s some confusion of that in the literature, but I’d be pretty certain to say, that the amount of sleep we need as we get older, doesn’t change. It’s just, we tend to take it at slightly different times.

Bilal Hafeez (00:23:30):

Yeah, it’s more interrupted. So ends up being sort of different. I think maybe we spoke about this before, but if one wanted to find out how much sleep you personally should get, I mean, one thing we talked about was the way to determine that would be while you’re on vacation, don’t set an alarm clock. And then by week two, whatever hours you’re sleeping, that’s probably the amount of sleep that you should have.

Adrian Williams (00:23:56):

Yes and no. Yes, you paraphrased it very well. In fact, it comes from the original studies where people were asking questions. I mean, how much sleep do we need? So they took a very privileged group of students to some Caribbean island and said, “Just sleep. Sleep as long as you want.” And the first two days after arriving, they would sleep on average nine or nine and a half hours to make up for the lack of sleep in their previous whatever, but then settled down to an average of eight with the range I just described. It was a very almost non-scientific study.

There have been population studies where that’s been slightly confirmed – if you ask huge populations how much they sleep, and of course Fitbit has been able to slightly help this. And then the amount of data that can come out of remote monitoring, even though it’s imperfect, when you have millions of people doing it, as you know, mathematically, you can still work out what the average is.

Does Catch-up Sleep on the Weekend Help?

Bilal Hafeez (00:25:04):

Yeah. And we’ll come back to some of the texts a bit later. And another question about sleep is this idea… You alluded to this with older people in their sort of siestas. So this idea of having a siesta, so this afternoon nap, you often see in Mediterranean cultures or I imagine in older sort of times, and even Northern cultures. And then also sleep kind of catch up. So, I mean, can you kind of break your sleep down? So, let’s say your body is inclined to eight hours of sleep. So you say, “Okay, I’ll do six hours overnight and then I’ll have a two-hour siesta. So I’ve got my eight hours and I’m done.” And equally, if over the course of the week during the weekdays, I’m getting six hours every day, so on the weekend, then I’ll try to sleep 10 hours a night for the two days on the weekend to kind of make up 10, 11 hours. I mean, can you kind of rearrange your sleep into blocks?

Adrian Williams (00:25:54):

Yes, your question was very precise. And there are two or three answers. Society does statistically sleep an extra two hours the weekend to make up for lack of sleep in a week. I’d interject that the one hour of lack of sleep on a particular night will have its effect on a subsequent day, so it doesn’t absolve you from the imperfections on those days certainly. And of course, if you decide to limit your sleep night and take a nap – if you go back to my idea that sleep is made up of this bulk of non-REM sleep and then much later a bulk of REM sleep, so the Spaniards might go to bed at 1:00, have to get up at 4:00. They’re going to have mostly non-REM sleep, restorative sleep, but they’ll be missing out on some REM sleep. And they’ll take a nap, a siesta. But it turns out that you don’t do much REM sleep in a siesta. So that is not perfect. Although, I have to say the power nap has its real positive aspects.

I’m not sure you were leading me up to another anecdote, and you’d have to tell me to stop. But going back to the animal experiments, which every sleep trainee knows about, rats which were deprived of all sleep die in two weeks. Rats deprived of REM sleep die in four weeks. But before that point, the rats deprived of REM sleep become hyper-sexual. And this is written about in the paper. They were described as mounting rocks. And so there was an idea that lack of REM sleep leads to some hypersexuality.

Bilal Hafeez (00:27:48):

Ah, interesting. And one can extrapolate this and impose it on cultures which have siestas ended up becoming hyper-sexualized possibly. So it’d be interesting one to study.

Adrian Williams (00:27:59):

Yes, indeed. Totally unproven aspect. Although I have to add that (you can’t do the sort of experiments like that in humans) but people have been REM-deprived and then shown explicit photographs. Their eye movements track the erogenous zones more in the REM-deprived than the non-REM-deprived. I mean, these are real experiments that have been done. I only just maybe interject all of that for amusement.

What Triggers Sleep

Bilal Hafeez (00:28:31):

That’s good. And in terms of triggers for sleep, we heard of circadian rhythms and things like that. So how should we think about the trigger for sleep? You’ve mentioned earlier toxins being built up in our body as well.

Adrian Williams (00:28:44):

Yes, indeed. It is quite clear the things that drive sleep. First of all, prior wakefulness. It’s a homeostatic of controlling the internal environment. So getting rid of toxins, that’s one, the homeostatic. But the other is the circadian influence, the body clock, which has a profound effect. We are most sleepy, and no one will be surprised by this, overnight. But there’s an internal clock which drives us towards sleep – the main sleep time around 4:00 or 5:00 AM. And also, another time in the afternoon when there’s that drive to sleep. So, when we think of a post-lunch dip, it turns out it’s not food-related, it’s actually a body clock-related thing. So, if there’s any tendency to sleep because we’ve not had enough sleep, that would kick in mainly around in the early hours of the morning 4:00, 5:00, 6:00 AM, which is when road traffic accidents are their peak or also in the middle of the afternoon.

That’s the drive to that. There’s very much a pattern of intensity of needing to sleep. So, add to that the chemical drive to sleep. So those are the two factors that are most influential. And I guess age is the other thing, and I guess environment. Even if you were sleepy, you wouldn’t sleep in front of a tiger. And there are environmental issues. But equally, if you need to sleep and you’re in a quiet lecture or a lecture hall, then you might. And you might’ve heard me say before, when I am giving lectures, and I do say to people that it’s quite common to fall asleep when Williams is talking. It’s understandable, but it’s not normal.

Bilal Hafeez (00:30:43):

I like that. Yeah, that’s good. Are there sort of signs of lack of sleep that you kind of look out for? I mean, somebody could say, “Look, I’m feeling tired.” So is that enough to tell you that they’re not getting enough sleep, or what types of things do you look out for?

Adrian Williams (00:30:59):

Well, the international standard, the true international standard of whether one is sleepy is a simple questionnaire called the Epworth Sleepiness Scale. And you ask a person to estimate their tendency to doze in one of the eight situations on a scale of one to three. Sitting down after lunch, a number of other things. So it’s very much subjective. And I say, it’s the international standard, because it’s used by the DVLA, for example, to make a judgment as to whether somebody is safe to drive. We all find it very puzzling, but we use it completely and universally. If one needed to be more objective, there are efforts to do that through laboratory studies. And they are validated and used, but they’re quite complicated. So, at the moment there isn’t a simple blood test that can identify an individual.

I might jump way back to a comment about driving. I mean, how would you judge somebody is safe to drive? And that is the technology that is moving ahead there with blink rates as one is tending to fall asleep. The palpebral fissure, the distance between the two eyelids, tends to drop, and then the blink rate drops. There are artificial intelligence systems that are being developed there. It’s a subjective statement. I am sleepy, or I am not. That’s a very real situation, but many people who are deficient of sleep are actually in a sense unaware of that. They become accustomed to it, and don’t declare it as, “I am sleepy,” but they’re still impaired.

And there’s a scientific example of that with performance testing with reaction times. They do reaction times in people with sleep deprivation, and it gets worse and worse and worse. But you ask them how they’re doing, and it levels off. So, extrapolate that out into the truck driver who is not sleeping because he has sleep apnea. It’s quite worrying that one’s perception of one sleepiness is real to oneself, but it may not be a real measure of one’s performance, and that could translate into finance sector work habits, I guess.

Sleep Apnea and Snoring

Bilal Hafeez (00:33:24):

Yeah. And you mentioned sleep apnea. I mean, you mentioned this when you talked about your early part of your journey into sleep medicine. I mean, can you talk a bit more about what sleep apnea is, the types of people or the physiology that lends itself more to sleep apnea or those sorts of things?

Adrian Williams (00:33:41):

Yeah, that’s easy for me to do. It’s a big part of the business of sleep. So just historically, just very quickly, sleep apnea wasn’t known of until 1965, in a medical sense, although Dickens are described it. And it revolves around the anatomy that we’re all given, which is the need to breathe and swallow through the same area in the throat, which is not supported by muscles. So, then it has the capacity to collapse or narrow to the point that someone might become a snorer. Now, this is the way I normally approach the discussion in patients. Snoring is extremely common. Half of men in middle-age snore, and that’s because the breathing passage is narrow enough in the area of the throat to allow the palate to flap around. So if that’s the case, you could imagine that the tube might reach the point of closing off and that’s called sleep apnea, which is also extremely common with a half of snorers.

So, it’s one in four men, and one in six or seven women have some interrupted breathing when they’re asleep. Remember that sleep is a relaxation and therefore the muscles relax. So that’s very common, unnaturally common and the design is clearly not right. When it’s a few instances, it doesn’t do anything. And it happens first in dreaming sleep, because as I said earlier on, when we’re dreaming the body’s paralyzed, but including the muscles in the throat. So that’s when it first kicks in.

When it becomes more throughout the night, then restorative sleep is interrupted and sleep therefore becomes non-restorative. And that might happen in one in 10 people. It’s a hugely common problem and driven also by increase in weight. Won’t surprise anyone to know that as we gain weight, the breathing passage in the throat narrows, and perhaps as we gain weight around various bits of us. But weight is hugely relevant to change in someone from just a snorer and to someone with sleep apnea.

And then the consequences of that, which is a huge focus for the NHS and for medics is the disruption of sleep leading to daytime sleepiness. And that’s an issue around driving and performance and work. And the nighttime with its snoring aspect might disrupt the family. And then the physical consequences are also quite well established. High blood pressure is a well-recognized outcome of having sleep apnea.

That’s because every time there’s an interruption to a breath, adrenaline is secreted as part of an arousal that over time leads to development of high blood pressure, heart disease, stroke. And the sleep community, and I know this is true, think that diabetes is also promoted by significant sleep apnea. 80% of diabetics have some sleep apnea and 25% have quite moderate to severe sleep apnea. So there is a link between the two. When you ask the sleep community where is it proven? There are hesitations, but it’s a very strong argument that sleep apnea is very much a part of the development of diabetes.

Bilal Hafeez (00:37:11):

And then how does one, I’m not sure if you can say cure, but how does one cure sleep apnea or manage sleep apnea? And how does one manage snoring? Well, reduce snoring. I mean, you see all these kinds of ads for snoring devices that you put in your nose and things.

Adrian Williams (00:37:28):

Indeed. No, those are very appropriate questions. So taking into account my description of the pathology of snoring and sleep apnea is the size of a breathing passage. So that the treatment is to keep the breathing passage open while one is asleep. Now, there are no medications yet available to activate the muscles. They are being searched for and there are some examples out there. So the future is bright for medication, but not there yet by any means. And then surgeries are hardly ever done to the throat these days.

Now the caveat there, if you have very big tonsils, which might encroach on the breathing passage, they need to be taken out. But surgeries are almost banned. They’re not done very often on the throat. And so we rely on devices. And for the milder end, which is snoring and mild sleep apnea would be a dental device, something that you would wear while you’re asleep, like a footballer’s mouth guard to bring the jaw forward. It’s very effective.

And then in the more severe of the spectrum, something which many people will have heard of called C-PAP, continuous positive airway pressure. So a pump device which sits on the bedside table attached to a comfortable nose mask, and then a small amount of air pressure keeps the breathing passage open. Now, the future may be brighter than that, I have to say. Personalized medicine, sometimes the issue is around the muscles not being active enough, and that could be treated by electrical stimulation. I’ve got colleagues with guys who are using external electrical stimulation to keep the muscles active. And there’s also an intra-oral device, something you would use in the day to stimulate the tongue muscle, which is the main muscle.

So, there are all these things coming down the pipe. And I think we have to be optimistic because I guess currently, when it comes to a large number of people offered this C-PAP treatment, which is the gold standard, my experience is that a third world will not want to carry on with it, even being advised and it works, because it’s just not the best answer.

Bilal Hafeez (00:39:57):

And you mentioned that men are much more likely to snore. And I think most people anecdotally, they’re aware of that, and men suffer more from sleep apnea. I mean, why is that more than women? Why aren’t women …

Adrian Williams (00:40:11):

The physiological argument given is that premenopausal women have progesterone around, which is a respiratory stimulant, which stimulates these upper airway muscles. I think that’s certainly the thing we talk about in lectures, I guess. You can again hear the hesitation in my voice. Probably that we don’t fully understand it. Weight might be the thing or men tending to be bulkier in their earlier age, but certainly women can catch up to men postmenopausally in terms of numbers. And I’d come back fully to the idea that it’s the anatomy that we’re born with that predisposes us to some of these issues around snoring and therefore the potential for sleep apnea.

Sleep and Temperature

Bilal Hafeez (00:41:02):

I want you to talk a bit more about some of the practical sides of sleeping. And I understand that temperature is quite important to being able to sleep well. So the temperature of the bedroom and the blankets, whether you’re overheated or not. Is that the case?

Adrian Williams (00:41:19):

Yes, it is. It is. One of the functions of sleep is to cool the brain. We lose a full degree centigrade overnight. It’s matched to the rise in the melatonin, which may be part of the influence. But the hotter the body is in the day, the more likely we are to go to sleep and stay asleep, and that’s through exercise, which is one of the pillars if you like, of sleep hygiene. One of the things that people can do that’s most likely to help their sleep. So having a cool bedroom, cool, dark and quiet.

A long time ago saying, bats are fantastic sleepers in their cold, dark caves. But that’s tongue-in-cheek actually. No, cool, a dark environment is conducive to sleep because losing temperature is one of the drives to sleep. That’s been explored in the hunter-gatherer societies by colleagues from UCLA. And it is the fall in ambient temperature that tends to be associated with the onset of sleep. So, if you’re in a warm environment, just makes it more difficult to get to that point of losing your own temperature to let sleep happen.

Managing Jet Lag

Bilal Hafeez (00:42:31):

And then many people, many listeners here, well, I guess not recently with the pandemic, but in more normal times, many people would travel across time zones and suffer from jet lag. Is there any kind of accepted view on managing jet lag? People talk about taking melatonin or adjusting your watch as soon as you get onto the plane to the time zone of the country you’re going to and trying to force yourself to stay awake or go to sleep early and things like that. I mean, are there ways of managing this?

Adrian Williams (00:42:57):

Yes, there are there. They’re imperfect, but it is around trying to speed up the change in your own body clock because that’s the thing that will make things easier at the other end. But the body clock has its own slow time changing. And so, you start by living a life closer to where you’re going to end up. And melatonin can help. And there are apps which are quite reasonable about this, about changing behavior and when to take melatonin and using dark glasses. Light is by far the most important stimulus to the body clock. So, we haven’t talked about this, but the body clock is forcing sleep at certain times with a rhythm that is very ingrained. And if you expose someone to light, for example, before 4:00 AM, then it will force the body clock to a later time.

So children, for example, who use their cell phones and computers at 11:00PM and 12:00AM are forcing their clock to a later time, making it more difficult to get to sleep. And equally, if you have light exposure after 4:00 AM it pushes the body clock the other way. So we use light that way. But when you’ve moved to a different time zone, your body talk hasn’t, so you’re exposed to light when it may be extending the problem. So dark glasses, and it does become quite complex, but people might be interested in looking at some of the apps that are available, at least listening to what they have to say around dark glasses anticipating the new time zone and melatonin.

Melatonin, Sleeping Pills, Caffeine and Alcohol

Bilal Hafeez (00:44:49):

Okay. And melatonin, even outside of a jet lag kind of context, if you take melatonin, does it help you fall asleep?

Adrian Williams (00:44:58):

Yes, it does. There are two answers to that. When taken, it can have a soporific effect to help people get to sleep. It’s not a hypnotic. That is not a sleeping tablet. But it also has an effect on the body clock. So when you can use it at a much earlier time to pull the clock towards it. I’m sure that’s very obvious in what I’ve said. So it has two uses in sleep medicine. One is to adjust the body clock. The other is to sort of slightly help people get to sleep. But I stress, it’s not a, I use the word hypnotic. It’s not a sleeping tablet. And that has its positive aspects. I mean, for me, I’m slightly prejudice. I think it doesn’t have any downsides.

Bilal Hafeez (00:45:43):

And there’s more conventional sleeping pills. Does that accelerate putting you to sleep or not?

Adrian Williams (00:45:51):

They work. But then the problem with the sleeping tablets is that the body becomes used to them. So one becomes habituated. And what I hear in clinic all the time is, “They helped me, but then I stopped taking them and I can’t sleep.” And so they go back on them. And that’s the issue that I think the general practitioners may advise not to prescribe because that’s a huge issue. People become used to them and therefore want to carry on taking them. And the what’s the downside of that? The sleep isn’t necessarily normal. And if you have a sleep agent on board and medication, if you wake to pee, they make you unstable. I mean, there are those issues. And does cognition change? An unanswerable question I’m not going to answer that. But these are questions that are being asked.

Bilal Hafeez (00:46:43):

Okay. And then I wanted to talk about two substances or chemicals, caffeine and alcohol. So caffeine, obviously that it’s a stimulant, it keeps you awake. But yet, I see lot of people have a coffee after their supper, after their dinner in the evening. And I kind of wonder how they fall asleep. I mean, how do you think about caffeine?

Adrian Williams (00:47:02):

I think about it in the terms of what a patient or a person would be complaining of. If you go back to a comment I made earlier on – a third of the population have a physiology which permits poor sleep because they have raised levels of adrenaline and cortisol. Now I stress that is not abnormal because it’s so many people. But it predisposes that population to poor sleep. And in that part of the population, if one has developed poor sleep, caffeine may be a powerful stimulant, but maybe not in the other two thirds. I’m hedging my bets here, but I think there is a difference between the people who are tending to be insomniac and the people who don’t. So you have friends who take coffee at midnight and it doesn’t matter. Well, there may be different than your friends who have some difficulty getting to sleep.

And the other important aspect of course, is that caffeine has a long half-life, much longer than most people realize. The chemistry of it is that if you take a strong Starbucks, 10:00 o’clock, 115 milligrams because of the half-life it degrades. And by 10:00 PM, there’s still 20 or 30 milligrams around. It has a half-life of five hours. I forget the actual calculation. So if you are sensitive, even certainly afternoon, it would be an issue. And that’s what we talk about in clinic, noon or 2:00 PM. So that’s the effect of caffeine on someone who’s sensitive. And that may be a large number of people.

Alcohol has the other effect. Of course, it tends to help sleep in a sense, put people to sleep. It does that. But after it’s been metabolized, sleep is more disrupted. So the whole total sleep experience is not as good. So, it’s always advised to stop alcohol three hours before bedtime, by which time it should have been metabolized.

Are Morning Larks and Night Owls A Myth?

Bilal Hafeez (00:49:01):

Okay. So those are sort of two things to look out for. Well, one thing I forgot to ask about is night owls and morning larks. By that, I mean presumably there’s certain people whose body clock sleep is they just going to bed later, yet society is structured for morning people essentially. Everything kind of starts early in schools and so on. Is it, is it true there are people who are night owls and how …

Adrian Williams (00:49:28):

Absolutely. There’s no question around this. The distribution is that the most people are morning, but a large proportion of the night and that is the body clock. It’s driven by five genes; they’re well characterized and a variation in those genes will make one shift from one to the other or be one or the other. They’re not called abnormalities. They’re called polymorphisms, because they are inherent there. But you can imagine if somebody is an evening person, preferring to go to bed at midnight, there may be people will want to go to bed at 1:00 or 2:00 or 3:00AM that then drifts into, well, the medics would call it a disorder, a delayed sleep phase syndrome happened to be part of the group that first described the gene changes in that. So it is a very real thing and the genes can’t be changed currently.

And so eveningness can’t be immediately changed, but you can shift the clock by manipulating light exposure a little. And so more light exposure in the morning and less in the evening will make the evening less. And yes, you’re right; society is probably geared towards the morning person, isn’t it? Our children are actually rather subject to that because there’s that natural adolescent change in the body clock just for some reason changes for a period to become more evening, and then you give them a computer or a cell phone, the blue light just makes it worse.

How Accurate Are Fitbits in Tracking Sleep?

Bilal Hafeez (00:51:06):

And at the beginning of our conversation, you alluded to some wearable technologies. You mentioned Fitbit and so on. I mean, these devices kind of claim that they can monitor your sleep really well and you can have little charts showing how well you’ve slept. Do you have a view on these sorts of devices?

Adrian Williams (00:51:22):

I surely do. My sleep community would expect me to say that none of them have been validated. I’ll come back to that. But there is a sleep disorder that was invented two years ago called … I have forgotten the name of the sleep disorder, but it’s about people coming into the clinic with their Fitbits and say, “Look how bad I’m sleeping. I’m doing everything right. I’m going to bed earlier.” I mean, I’m doing all the wrong things because their Fitbit hasn’t been validated. So most of their devices are not validated. They’ve done their internal business reviews.

But having said that, there are developments within that. And I think the new Fitbit has got better. I mean, it’s quite intriguing what you can do from device, wearables. Originally only movement was tracked, but now the devices have picking up pulse rates and even skin temperatures, which are both altered by sleep and by REM sleep. So they can become a bit more specific. So, some of them are getting closer. But I’d have to stress or ask my sleep community will take me to task. They’re not validated at all to use them as real devices. We use some medical ones which are, but not the commercial. Is it a good idea to do this? I suppose in general it is to know. But equally, if it generates worry and it becomes a problem.

Tips for Better Sleep

Bilal Hafeez (00:52:51):

And just to kind of round off this kind of the main part of our conversation, I mean, what, what sort of general tips would you leave for our listeners in terms of tips to sleep well?

Adrian Williams (00:53:01):

Yes, so they’re the usual ones of sleep. So if you went to a clinic and were being coached in better sleep, there would be three elements. This is probably the best way to put it. One is sleep hygiene and that’s the around all the good and bad things that we all need to pay attention to. And I’ve distilled them down in my long experience to avoiding afternoon caffeine if you have a problem sleeping. Exercise, which is hugely good for sleep. And I belong to a group who thinks that timing of exercise might be important. If it’s around body temperature, which I think it is, then, if you exercise in the morning, then the temperature you generate will be dissipated in the day and won’t be there at night. If you exercise and the late evening, then adrenaline levels will disturb sleep. But if you exercise in the late afternoon, then that temperature load will be there to help you sleep.

Similarly, a warm bath and an hour before bedtime is helpful because of the temperature and the bedroom. Cool, dark and quiet with no electronics, no time cues. To be reminded of the time if you wake up will almost guarantee you continue waking up at that time. So no time cues, as frustrating as that might be. And then getting up at the same time every day, regardless of how little sleep you’ve had. Those are the sleep hygiene rules.

Bilal Hafeez (00:54:30):

Just on one point you mentioned late afternoon exercising is optimal because of the sort of tradeoff between body temperature and adrenaline. Late afternoon is defined as what times?

Adrian Williams (00:54:39):

4:00 to 7:00 PM. Now it’s not ideal, and sadly that’s the way it is.

Bilal Hafeez (00:54:47):

Okay. No, that all make sense. So I mean, things like listening to music or the radio while you’re falling to sleep, is that …

Adrian Williams (00:54:55):

Yes. I mean, I think it’s those things. Yes, they’re okay. Certainly having light signals, meaning candles and television is not a good thing or phones. It’s the light which is the thing that might influence the body clock and the ability to get asleep. But I guess there are interesting ideas about when you are asleep that some sounds may actually help, but I don’t think that’s a problem. Because what I haven’t touched on is alcohol, but we did earlier on. Alcohol will help you get to sleep, but then will tend to make your sleep worse. So nicotine has that same sort of effect. And knowing whether you have a sleep disturbance, which is independent of all that. Do you snore or do you have restless legs? I mean, that’s the other common sleep disorder. I know we probably, haven’t got time to get into that.

Adrian’s Productivity Hacks and Book Picks

Bilal Hafeez (00:55:48):

Okay. No, that’s great. And before we kind of end our conversation, I do like to ask a few personal questions. I’m a researcher, so I have to ask this. One is, how do you manage your kind of information research flow? Because, obviously, presumably, there’s huge amounts of research that you have to kind of digest somehow. I mean, how do you work? Do you have a system to kind of digest this all or manage this?

Adrian Williams (00:56:14):

I think a life in medicine has always been around needing to keep up with things. And so I now focus on the sleep issues. In this electronic world, in this internet world, it’s not hard to have very defined searches come through. One of the problems with sleep is that it is very much general practice because it affects all our organ systems. We hadn’t made this point, but it really does. It’s neurological, it’s cardiac, it’s lung, it’s diabetes. So I do describe myself as a general practitioner of state. The word state means we exist in one of the three states. We are in awake state or we are in non-REM sleep or in REM sleep. So each of them has its different effects. But so that’s a bad answer to your question, but it’s just focused internet stuff and reading colleagues’ books.

Bilal Hafeez (00:57:21):

And speaking of books, I love reading books. And so I always like to ask my guests, what book or books influenced you the most, whether personally or in a work context?

Adrian Williams (00:57:30):

Yeah. I have to strive to answer that with the sleep context. Sleep was first investigated properly in the 1930s. And there’s a very famous book called Sleep and Wakefulness by a man called Nathaniel Kleitman who died just three, four, five years ago at 101. He’d had a sleep study every year of his adult life. And first wondered about sleep. And then the next serious person and was an acquaintance of mine in California called William Dement, who first discovered REM sleep. And he wrote something called The Promise of Sleep. And other friends who’ve written books like that. So those are the things I’m bound to focus on early on. But beyond that, I mean, I do have other major interests. My family criticize me. Never novels, but around biographies and people who have made a mark and the science in scientific world.

There are two that I particularly relate to. First Richard Feynman and his biography by James Gleick, but also his own book called Surely You’re Joking Mr. Feynman! A wonderful man. And you could only wish to emulate him. And also, Watson and Crick and the DNA stuff, which actually has led me to my most recent book, which I guess is not what you were asking, but it’s the biography by Isaacson of Doudna, the Nobel Laureate, the woman who discovered CRISPR the genes and the way the world is changing and what science can do.

Sleep is a long way behind us. It’s still so observational, with so many things we can’t actually deal with except lots of things we know are important. Meaning getting as much good sleep as you can. I sound like a prophet. But I think that’s so important even if we don’t understand fully why it is fairly clear now at this point, that sleep is hugely therapeutic.

Bilal Hafeez (00:59:44):

Okay. No, that’s great. And so if people wanted to follow you or connect to you, consult with you. I mean, what’s the best way for them to do that.

Adrian Williams (00:59:54):

Yeah. I don’t have this nice thing you’re doing, but it’s just email and I’m happy to put you put that out.

Bilal Hafeez (01:00:02):

Okay, great. Yeah. I’ll do that. So with that, it was great speaking to you and thanks again for providing very enlightening discussion.

Adrian Williams (01:00:10):

Pleasure. Lovely to speak to you, too.