How Do I Sleep Better? with Dr. Reller & Dr. Nishi Bhopal

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I am joined by Dr. Nishi Bhopal, a psychiatrist and sleep specialist, to dive deep into the world of sleep medicine. In this episode, we explore the crucial components of the CSH framework: Circadian Rhythm, Sleep Drive, and Hyperarousal. Dr. Bhopal shares insights on how to optimize your sleep quality through light exposure, managing screen time, and understanding your body's sleep drive. We also discuss integrative and holistic approaches, including nutrition, exercise, and supplements, to enhance sleep health. Tune in to learn practical tips for improving your sleep and overall well-being.

Nishi Bhopal MD is board-certified in Psychiatry, Sleep Medicine, and Integrative Holistic Medicine. She is the founder and medical director of Pacific Integrative Psychiatry, an online practice in California where patients receive a whole-person approach to anxiety, depression, and sleep disorders, including nutrition, psychotherapy, and integrative and functional medicine.

In addition to her private practice, Dr. Bhopal is the founder of IntraBalance, an educational platform for physicians and therapists that includes a YouTube channel and online courses on clinical sleep medicine for healthcare practitioners. Her passion is making clinical sleep medicine easy to understand and accessible to all.

00:28 - Introduction and Guest Introduction
01:08 - Dr. Bhopal's Journey to Sleep Medicine
04:40 - The CSH Framework Overview
09:14 - Importance of Light Exposure for Circadian Rhythm
12:18 - Managing Screen Time and Sleep
18:40 - Understanding Sleep Drive
23:08 - Hyperarousal and Sleep
29:54 - Integrative and Holistic Sleep Approaches
36:57 - The Role of Supplements in Sleep Health
47:57 - Dr. Bhopal’s Courses and Where to Find Her

LinkedIn: https://www.linkedin.com/in/nishibhopal/
Youtube: https://www.youtube.com/c/intrabalance
Instagram: https://www.instagram.com/intrabalance
Facebook: https://www.facebook.com/IntraBalanceLLC/
Private practice website: https://pacificintegrativepsych.com/

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Transcript

Kerry: 0:28

Hi everybody. Welcome back to the get healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller And today we have a very special guest who I should have asked how to say your last name, but Dr. Nishi is what you said you'd go by, but also how do you say your last name?

Nishi: 0:42

It's Bhopal.

Kerry: 0:43

Bow paw. Okay. I should have asked that first. Sorry. Anyway, so do you go by Dr. Nishi according

Nishi: 0:49

Yeah. Dr. Nishida on social media. Yeah.

Kerry: 0:51

Yeah. Awesome. Okay. Well, welcome to the podcast. I'm so excited to hear a bit about who you are and what you do and share your expertise.

Nishi: 0:59

Oh, thanks so much for having me. Yeah. No, I'm really excited to talk about sleep, which is one of my favorite things to discuss. So yeah, no, thanks so much for having me.

Kerry: 1:08

So how did you I guess get into, I mean, I know you're a psychiatrist and sleep. So how did you get into all this? What happened?

Nishi: 1:14

Yeah. So when I actually went to medical school, I thought I was going to be a pediatrician. I did not set out to go into psychiatry and I didn't even know sleep medicine was a specialty that you could do. So you know, I'm in med school and I realized peds wasn't for me. And then I decided to do internal medicine. So I went down that whole track of applying for internal medicine residency. I got into internal medicine residency. I was always interested in psychiatry as well, though. My dad's a psychiatrist, so I had exposure to it through that, but I was one of those students and I I'm still one of those people. I just love to learn. And I felt like internal medicine encompassed a lot of different areas. And I had trouble kind of narrowing it down just to, you know, one specific specialty. So I thought, okay, well, this is pretty general and there's lots of subspecialties you can do. But when I got into my internal medicine residency program, I found myself talking to my patients about their mental health, their life, meaning, purpose, did they enjoy their jobs, what was their relationship like with their families, and all of these kinds of things. And then I realized, Okay, wait, maybe I should have done psychiatry after all. And so I ended up switching into psych after my intern year. And during my psychiatry residency, I had a senior res, actually, I met the senior resident when I was in internal medicine, and she was going into sleep medicine fellowship. And I hadn't heard of sleep medicine before. I mean, I knew it was like Kind of a thing, but I didn't know it was a specific fellowship that you could do it. So, I mean, this is way back when the sleep is a lot more popular now, but that just kind of got me interested in learning more. And then, as I was going through my psych residency, I was noticing how many of my patients were struggling with sleep. Because there is a relationship between sleep and mental health, and I felt like I didn't really have good tools, or enough tools, to help them. And then me, personally, I'm someone who's always struggled with a little bit of sleepiness, like not insomnia, but hypersomnia. being sleepier than my peers. And, you know, oh my gosh, I can tell you. Yeah, totally. I know. And so residency was so hard because we're sleep deprived, right? At baseline. So I really struggled. And then I saw my patients struggling with insomnia, hypersomnia, all other kinds of sleep disorders. And that really piqued my interest in going into sleep medicine. And yeah. And so I started doing rotations in that and ended up pursuing a fellowship.

Kerry: 3:37

Yeah, that's awesome. I, I don't really know when I learned about sleep medicine, but I think I even saw on your website that most doctors don't get much training in it at all, which is so true. I don't remember learning anything. So what I've, you know, learned to counsel my patients on is Probably just stuff I picked up along the way, like, you know, nothing in a formal setting. Yeah,

Nishi: 3:58

Yeah.

Kerry: 3:59

Under, you know, learned underutilized and I think like you said it is kind of growing though since, since more recently. Yeah, so that's great. I also would say I'm like hyper insomnia meaning like I remember just being passed out in classes and every age, like from high school, college, like it's just, I fall asleep. You know, easily and always joke of the family that I'm narcoleptic, but I'm not. So, we heard your story about how you got into everything and then now you're really focusing on integrating the two of psychiatry and sleep and you have a special framework that you were kind of reluting to. So can you tell us about that? What does that mean?

Nishi: 4:40

Yeah, okay yeah let's let's jump into that so I call this the CSH framework, and I'll just explain a little bit about, you know, why it's helpful to have a framework, because sleep, often feels kind of abstract or murky like it can feel hard to get. You know, just a good handle on what's going on. Like, I know when I was struggling with sleep issues and you were sharing, you know, as a kid and teen, like throughout your life, you had issues with being excessively sleepy. Me too. Like I'd come home from school and want to take a nap instead of going to play with my friends or, you know, falling asleep in my university classes. I would make sure I didn't have like 8am classes because I would not be able to stay awake throughout the day. And so I just, I felt like I could never really get a handle on my sleep. I didn't really understand what was going on. And I also don't have narcolepsy. There is a condition called narcolepsy. And so if people relate to these symptoms, do go get it checked out just to make sure. But so anyway, so I use this framework with my patients and I teach this to doctors as well, and it just makes it easier to figure out what's going on with your sleep and also to optimize your sleep quality. So it's called the CSH framework. C stands for circadian rhythm. S stands for sleep drive. And H stands for hyperarousal. So if you're struggling with insomnia or excessive sleepiness or irregular sleep schedules, you can work through these three elements to address each of them to really optimize your sleep and see, and also to see what might be going on, what might be the underlying cause. Cause if someone's struggling with sleep issues, there could be lots of different contributing factors to it. So I can, I can explain more about each of those, I'll just pause there and, and, and see what questions you have.

Kerry: 6:17

Yeah, I already forgot what the S and the H stand for. I was trying to write it down. But yeah, so this will, this will be really interesting, especially with I'm currently reading the Good Energy book by K. C. Means. I don't know if you've heard of it, but she does pretty much a deep dive on sleep and a lot of it's about the circadian rhythm. So I would love for you to tell us about that and what it is, if some people don't know.

Nishi: 6:39

Absolutely. The S and the H were sleep drive and hyperarousal, so we'll talk about those. Okay, circadian rhythm is essentially your body clock. Every living creature on the planet has a body clock, right? Even plants. And it was actually you know, discovered with these plant experiments with Plants that would kind of you know, close up their leaves at night time, even when they're put in a box, when they're not getting exposure to sunlight, and then open up their leaves during the daylight hours in these controlled experiments. So our body is like that, right? So it's really attuned to light and dark cycles. Meaning sunlight and then darkness at night and in our modern world. We're so detached from those cycles because of artificial lighting, right? And this is not to disparage technology. Technology is wonderful and amazing. And there's, you know, like we wouldn't be talking right now if it weren't for technology, but it's also caused us to be more disconnected from it. Our natural cycles from the rhythms of the earth and that's really what the circadian rhythm is all about. So our, our circadian rhythm regulates the sleep wake cycle, but not just that because oftentimes people think of circadian rhythms in terms of sleep, but it does way more than that. It also impacts hunger cycles, our energy levels, levels of alertness, cortisol secretion, like all of these other things, blood pressure body temperature regulation, it really impacts everything. So there's a master clock in the brain that regulates all of this. And then our organs have their own little clocks. So the master clock is kind of like the train schedule and it's telling like all the different trains when they should be running. So in order to optimize sleep, so tying this back to sleep really regulating your body clock in simple ways. It doesn't have to be complicated, can have a very positive impact on sleep. So what this means is having a consistent wake up time, waking up around within an hour of the same time each day having consistent mealtimes. So having your lunch around the same time every day, having your dinner around the same time every day, and again, it's not going to be exact. We don't want to have too much rigidity around this. There also needs to be some flexibility or it can create anxiety. But within about an hour and then also regular exercise or times of movement. So regulating those three things, light exposure in the morning, having a consistent wake time, getting bright light. Regular mealtimes and regular physical activity can really set yourself up for good quality sleep at night.

Kerry: 9:09

Can you elaborate on the light exposure part that in the morning that what you're supposed to do.

Nishi: 9:14

Yeah, so light is one of the most powerful cues for the body clock. And we really want to exaggerate light exposure during the day and then exaggerate darkness exposure in the evening. So how we can do this practically is in the morning the ideal thing to do is to go outside and get sunlight natural sunlight for a minimum of 10 minutes, ideally before 10 a. m. And you can go outside without sunglasses is really important. Yeah, because we want to get the full intensity of that bright light in the morning. And just to give you an idea, because patients will ask me, like, what if I just sit near the window? And that's helpful too, to open up all the blinds and curtains and get natural light. To give you some more context around that, you can see because we're meeting on Zoom right now, but if people are listening to the podcast, they can't see, but I'm sitting in a really bright room right now. But in this room, it's probably about 800 lux, maybe a thousand lux of light intensity, LUX. If you go outside, I'm in California and it's really bright and sunny right now. If I went outside, that's about 100, 000 lux of light intensity, right? So even though it feels really bright inside, it's actually a lot more dim than we think it is. So you want to go outside and get that bright light, even if it's foggy, cloudy. It's not like a super bright sunny day, you're still getting a lot of light intensity. So you can still go outside and do that. Now for people who don't have access to that, or let's say, you know, you live in a place where it's like really harsh in the winter, and you're just not going to go outside, then you can use a light therapy device. And so I have information on my YouTube channel about that. But that's where those devices can be helpful. Now on the flip side, in the evening, we want to exaggerate darkness, because exposure to darkness enhances our bodies production of melatonin, and it also just signal, signals to your brain that it's nighttime. It's time to wind down. So what I recommend for this is to basically turn your house into a cave at night. So turn off the lights, especially the overhead lights. You can use table lamps, salt lamps think of like if you go camping, the type of atmosphere that you would have, like it's cozy, it's dark, you have some like, you know, orange glow from your campfire or whatnot. See if you can recreate that type of ambiance in your home at night. And that really does tell your brain that it's time to go to sleep. It's time to unwind. We can talk about screens as well, because I know there's like a lot of information out there on blue light and screens, and it's kind of a more nuanced topic than I think a lot of people realize. So I'll pause there again, but yeah, we can talk about that if you think there'd be interested in that.

Kerry: 11:53

No, I definitely think there's interest in that. I'd love to go into that. The only thing I would say of all the things that you mentioned previously about how the circadian rhythm is effective. One other thing would be like glucose and insulin resistance and metabolism and everything like that. So it really affects a whole lot more than we think. And I mean, some of this stuff where I think we're just learning, but Yeah. So tell us about the screens in the evening and what to do and what do you suggest?

Nishi: 12:18

Yeah, so, you know, there's this whole thing on social media about, you know, don't use your screens at night because of the blue light, but actually, the data behind this is not as robust as people might think this idea of blue light being quote unquote bad for sleep has really taken hold in popular science, but the studies show that exposure to blue light might delay sleep onset by an order of like, three to seven or three to nine minutes, something like this. So it doesn't have this huge impact that you know, we might be led to believe. Having said that though, this doesn't mean that You should be on your phone scrolling Instagram right before bed. There's other elements at play. So one is the actual brightness of the screen. You know, if you were holding a phone or a tablet, it's really not that bright. It's maybe like 80 lux compared to what a light therapy device would be emitting, which is like 5 so it doesn't have that level of intensity. So that's one thing, but I still do recommend dimming the brightness on your screen if you are using it and using the night shift mode. All those things are helpful. I'm not saying not to use them, but just want to, you know, shed some light, pun intended, on this issue. Dr. Michael Gratisar did a great podcast episode series with Matt Walker on Matt Walker's podcast. So if people want to take a deeper dive into the science on that, they can listen to that. But the other thing I want to highlight with screens is that it's not just about the light, but also the content of what you're viewing on the screen. So if you're scrolling Instagram, you're checking your email, you're doing work you're on TikTok, all those kinds of things are very stimulating for the nervous system and stimulating for the brain. And we really want to focus on allowing our brain to relax and rest in the evening, and doing these things on our screens is not helping. With that. So we want to be really mindful about what we're doing in the evening. So some of my patients will ask me, well, what about watching TV? Is that okay? And again, you know, it depends. It depends on what you're watching. If you're watching true crime dramas, probably not so good, right? But if it's something that helps you relax, it's an enjoyable show. Maybe you've even seen it before and it's not going to get you sucked into the storyline, but it's just something that helps you unwind, then it actually might not be so bad. And in fact, for some people, if they do tend to have a racing mind or a lot of anxiety at night, sometimes it can even be helpful to watch a rerun of You know, friends or, you know, whatever show they enjoy and they find you know, relaxing and comforting. So there's, there's more nuance here, but yeah, so I invite people just to start to pay attention to how these things affect you personally, because there's no one blanket statement or recommendation.

Kerry: 15:05

Yeah. No, that makes sense. I mean, certainly the content is a big thing. Like any of those, I don't know, scary things can make you, you know, have thoughts and keep you up and things like that. So that makes sense. very good points. Okay. Was there anything else that you wanted to say about the circadian rhythm component or anything like that? Yes.

Nishi: 15:23

let's see. So I think, yeah, so regularity is really key with this. The other point is, you know, we talked about consistency of the wake up time. What about consistency of bedtime, right? And patients will ask me about that. Well, should I go to bed at the same time every night? Again, it depends. For people who struggle with insomnia that can start to create more rigidity and anxiety, and it can actually feed into the insomnia. So, you have to be mindful of that. So having a little bit of flexibility with bedtime, meaning, don't get into bed until you're sleepy. Right? It's all common sense. But I see this all the time. Where People might think, okay, it's 10 p. m. I need to get into bed, and they're not sleepy yet, and now they're tossing and turning for another hour, hour and a half, and that can actually feed into insomnia. So you want to get into bed when you're sleepy and you're tired, and the signs of that are your eyes are heavy, you're yawning you might find that your, like, head is starting to nod, that type of thing. That's, that's when you want to get into bed. For people who don't struggle with insomnia then, you know, getting into bed, maybe reading a book or something like that. Yeah, that, nothing wrong with that, that can be helpful. But just, again, be really mindful about how these different behaviours work. impact you?

Kerry: 16:37

Any comment about like social jet lag that alters these time frames?

Nishi: 16:42

Oh, that's such a great question. Yeah, I love that question. So social jet lag is essentially that it's the same as jet lag, same kinds of symptoms. But we get that without traveling, and it happens when we have a different wake time on weekdays versus weekends or, you know, just different inconsistent wake times across the week. And you'll see this a lot with students. I know that I struggled with this a lot when I was in university and then of course in residency and in medical training. Where, you know, if you're getting up at say 6 a. m. on a weekday and then let's say 9 a. m. on a weekend, that's a three hour time difference. So it's like you're flying from San Francisco to Tampa. every weekend, right? And back. And then it creates this jet lag effect. And so people feel tired, foggy. You might feel hungry at weird times. You might have low energy and you don't have the energy to exercise or it's hard to focus and concentrate. Or some people get physical symptoms like headaches or nausea, or just like, you know, general aches and pains, fatigue, those kinds of things. So yes. Having that consistent wake time can combat the effects of social jet lag.

Kerry: 17:52

I feel like the people most vulnerable to this are the teenagers you know who need more sleep but school is like starting at seven or eight a. m and they're just not ready for that early start time because they're still sleep deprived. It's, it's really tough, I think, for our society even to alter those times, but they, they definitely suffer. It's tough to, tough to see when I'm watching my nieces and nephews who need more sleep.

Nishi: 18:17

Absolutely. And there's, there's actually a whole movement in the sleep medicine world to delay school start times.

Kerry: 18:23

Our school moved up five minutes this year. I was like, Hmm, why is that happening? We barely make it on time already.

Nishi: 18:30

Wrong direction.

Kerry: 18:31

Yeah, exactly. I wasn't happy to see that. Well, I think these are all really awesome points. Why don't you tell us a little bit about the sleep drive?

Nishi: 18:40

Great. Sleep drive is essentially your driver, your pressure to fall asleep. So it's kind of like hunger. Another way to think about it is like sleep hunger. So, you know, when you go to bed at night, you want to be hungry for sleep and how we can increase that sleep driver. That sleep hunger is one to be active during the day. The longer or not the longer, but you know, like the more active we are and then the longer that we're awake, we actually start to build up a neurotransmitter called adenosine and adenosine is what makes us feel sleepy at night. It's one of the things that makes us feel sleepy at night. It's a neurotransmitter that builds up. And then as we sleep, that neurotransmitter, adenosine gets washed out of the brain. So those levels decrease and then they build up again in the morning as the day goes on and then we go to sleep and it washes out. So adenosine we want to build up by having physical activity throughout the day. And this doesn't mean that you have to be training for a marathon or anything, but just being up and about that non exercise activity, you know, neat activities. So, being active also minimizing naps. Now naps can be helpful in certain cases, and we can look at that too, but You can think of naps as like sleep snacks, so if you are having too many snacks during the day, you're not going to be hungry for dinner. Sleep is like this too. If you're too sedentary or you're taking naps, especially prolonged naps during the day, you're going to be less hungry for sleep at night. So to increase the sleep drive, we can minimize those naps. However, there's a time and place for naps, which we can look at as well. And then with sleep drive, we also want to be mindful of caffeine. Because caffeine blocks the adenosine receptor. And so it makes you feel more awake and alert. So this is why around 2 p. m. in the afternoon, when we have a natural dip in our circadian rhythm, you see the lineup at Starbucks around the corner. Right? Because people want that caffeine hit to block the effects of adenosine that have been building up throughout the day. And so caffeine can impact the adenosine and then of course have a negative impact on sleep. So that's kind of sleep drive in a nutshell. And then I can share a little bit about naps, if that would be helpful.

Kerry: 20:46

Yeah, I was gonna say, I recently had an exercise enthusiast on, and we were talking about how good exercise snacks are, but perhaps the sleep snack's not so friendly. Yeah, why don't you tell us more about the sleep snacks

Nishi: 20:58

Yeah, exactly. Exactly. I love, I love that term, exercise snacks, sleep snacks, all these different kinds of snacks. So with naps. Naps can be helpful in certain cases. They're not recommended for people struggling with insomnia. So if anyone's listening and is dealing with insomnia, then you want to avoid naps because we want to build up your sleep drive even more so that you're more hungry for sleep at night. For people who are not struggling with insomnia, naps can actually be quite helpful, quite restorative. And in fact companies like, Huffington Post, NASA, Google, even Ben and Jerry's, they all have nap rooms in their offices, not because, you know, out of the goodness of their hearts, they want their employees to take naps, but it's really because of productivity, because taking short naps during the day has been associated with increased productivity, improved memory, cognition, alertness, and so on. So having a nap of about, 10 to 20 minutes before 3 p. m. ideally can be actually quite restorative. And this is something that I'll do during the day, especially someone who's like on the sleepier side. You know, I feel like I'm kind of dragging in the afternoon, I'll just lie down for like, 15 minutes I'll just put the timer on my phone. You might not even fall asleep during that time. But just having that rest with eyes closed without stimulation, right? So nothing on in the background, you know, no TV or anything like that, but just quiet can actually be quite restful to the brain and, and recharging. So yeah, if you, for people who are struggling with that little bit of a dip in the afternoon, instead of reaching for that espresso, Yeah, maybe try a nap.

Kerry: 22:38

that's, I wish I could do that. I don't know if that would work out in my schedule. We don't have a sleep room in our office, so I guess I can't do that. No, but that's, that's that's really good advice. I think that those that can work that into their schedule, that would be nice. And maybe we need to promote that for bigger offices to do that. Nice. Okay. So I think was that covering the sleep drive?

Nishi: 23:01

Yeah,

Kerry: 23:01

Okay. Cool. Okay. I don't really have any other questions on that. So why don't we go to the hyper arousal or not number H, but letter H.

Nishi: 23:08

sure. Yeah. Oh, actually, no, I did think of one more thing for sleep, which is one of the biggest mistakes that I see people making, especially when they're struggling with insomnia is spending too much time in bed. So and it kind of makes intuitive sense in a way because the thinking behind that as well. If I'm not getting enough sleep, let me spend more time in bed. So that I can get more sleep, and so the logic kind of makes sense there, but actually what's happening is it's reducing the sleep drive even more, and it's creating more sleep fragmentation. So we want to do the opposite, which is restricting the amount of time in bed so that the sleep drive is increased, and then the sleep that you're getting is more consolidated and deeper. And this is also known as sleep compression, or sleep restriction, or sleep efficiency training, because the idea here is we want to increase sleep. the sleep efficiency, basically, is that you're spending more time in your bed asleep versus being awake. And we want to break that association of being awake in the bed, Because it becomes this conditioned response where you get into bed and now you're just awake because that's what your brain is doing in the bed. So that's just another important point with sleep drive.

Kerry: 24:14

So that's like not working in the bed or reading and things like that, or I guess you could read before bed, but like watching TV or just spending more time in it. Yeah. Okay. That makes a lot of sense. Obviously. So how about hyperarousal?

Nishi: 24:27

hyperarousal is kind of a big category. So I'll just give like a high level overview of this. And essentially what this refers to is your nervous system being just kind of like in this overstimulated state. And this is counter active to sleep, right? Because your nervous system has to be relaxed in order to fall asleep. And there's basically two main branches of the autonomic nervous system. There's the sympathetic, which is the fight, flight, freeze, and fawn response. And then the parasympathetic, which is the rest and digest response. So in order to fall asleep, we need to be in that parasympathetic branch of our nervous system that has to be active to fall asleep. But, We're in our sympathetic nervous system most of the time, most of the day. And it's not that that's bad, it's just it. That's what we need to survive, right? To get through the day. And it doesn't just flip like a switch, right? So you don't just switch off the sympathetic and turn on the parasympathetic at nighttime, there needs to be a bit of a wind down, a bridge to shift in into the parasympathetic. But when people are having trouble. Turning down that sympathetic nervous system. It could be a sign of various kinds of things. So it could be that there's mental health issues going on anxiety, PTSD even depression, you know, things like this, that could be contributing, there could be medical issues, things like sleep apnea, restless leg syndrome, like other types of sleep disorders, it could be related to high blood pressure, you mentioned impaired glucose metabolism, metabolism and insulin resistance, These kinds of metabolic issues could be at play thyroid issues, right? So this whole kind of category of medical issues it could be related to stress that doesn't necessarily fall into a mental health condition, but just being chronically stressed and burned out. Even just having a lot of anxiety about sleep itself, which you see a lot with people struggling with insomnia, you know, right? Just having this kind of like fear around sleep that can drive that hyper arousal response. So. This is a branch to, to really look at. And you know, for people who are struggling with this kind of hyper arousal piece, this is where talking to a medical professional can be really helpful, even just starting with your primary care doctor, and then, you know, getting guidance on, you know, who would be the appropriate person next person to kind of, you know, evaluate this.

Kerry: 26:49

How can some people improve upon this like with methods on their own?

Nishi: 26:54

there's lots of different things that can be helpful. And I know that you're a big proponent of exercise. So I think, you know, getting movement, getting exercise during the day, it kind of like discharges that nervous energy that, that people can have, especially you know, I'm a psychiatrist, so I, people, I see people with anxiety and depression. And so exercise is so, so therapeutic. And it doesn't have to be, you know, that you're, You know, doing a triathlon or anything like that. It could be walking. It could be stretching you know, running after your dog, you know, those kinds of things can be can be really helpful. The other thing I do recommend to everyone is focusing on the breath, just doing some simple breathwork exercises. And you don't have to go to, like, a yoga class and, like, learn any complicated techniques. It could just be simply you know, taking an inhale and then an exhale that's twice as long as the inhalation. So just breath in through the nose, exhale through the mouth. There's a breathwork technique called the 4 7 8 technique that's really easy for people to do, and it's accessible, and you can just Google it and learn that. And I recommend My patients, and I do this myself too, but I recommend to people to do it like every hour, or at different checkpoints, so you know, before and after a meeting, like I'm on Zoom meetings all day, so, you know, before and after each meeting, I'll do a few of these like, you know, breaths, or, you know, before and after your meal anytime you're transitioning to something else. Just practice it. And it's actually very, very calming for the nervous system. So that's another one. The other one is to do a little bit of a digital detox. So again, going back to what we were talking about with the content of screens, we live in this day and age where we are constantly bombarded by information, by stimuli, by emails, text messages. I know we were like getting messages before we even started during this podcast. Right. It's, it's nonstop. So. Just creating a digital detox for yourself and what this can look like practically. I've actually been doing this lately and I, I really enjoy it, which is the bookend strategy. So basically no screens or technology for the hour after you wake up. And then again, for the hour before you go to bed. And it sounds really simple, but it actually, you know, can have a really profound impact on how you start your day and how you're, you end your day and then helping you to regulate your nervous system. And then. Half a day a week. I do recommend to people if you, if you can do this is to just have like half a day with no technology at all. Like, you know, like a Sunday afternoon or something or like, you know, Saturday morning or whatever, you know, works for you. And instead, go outside. And, you know you know, go for a hike, go for a walk, go to the beach or, you know, do some gardening or whatever it is but to go outside without screens half a day a week, oh my gosh, it can really, really do wonders for the nervous system.

Kerry: 29:54

I'm trying to think if I do that or not. Sometimes I do, sometimes we don't, but my husband's way better at that than I am with the no technology. So I mean, I definitely think it's doable. I feel like you have to be intentional about, or I would have to be intentional about it. So I think that that's really good. And then what else do you say the breath work? I haven't heard of the 478, but I've heard of some other versions of that. And I know you mentioned yoga. I think you had some yoga background or something like that as well, where you kind of learned some of these things to help you. sleep better, right? Yeah. And I often, like you said, like tell my patients, exercise, you know, isn't for losing weight. It's, you know, for mental health, bone health, all this, all these other benefits and not necessarily, you know, we're focusing on the weight thing. So totally, totally agree with that. It's really important and it helps for better sleep too, right? So it improves the quality of the sleep as well, which we didn't really discuss as much, but that's okay. So and then I guess I, with your framework, was there any other things that you wanted to add before we dive into something else?

Nishi: 30:55

So yeah, so what I would recommend is, you know, so that was a lot of information, right? And so it can feel overwhelming when you hear this and you're like, Oh my gosh, there's like all these million things now I need to look at. So just keep it simple and just take a step back. And so again, for anyone who is either struggling with insomnia or you're sleepy and tired all the time or you just want to optimize your sleep, just go back to CSH. Okay, where do I think I need to focus? Maybe I need to focus on my circadian rhythm if my sleep schedule's all over the place, right? Or maybe I'm spending too much time in bed, right? And maybe I need to focus on my sleep drive and increasing my sleep hunger. Or, yeah, my nervous system's active all the time and I find it hard to relax. Maybe I need to focus on that hyper arousal piece, right? So just checking in with yourself and I, I love that you mentioned being intentional about it. So just checking in with yourself to see, okay, what, where do I want to start? Or what even feels feasible, right? Maybe, okay, maybe I'll just start with getting bright light. So, I recommend just picking one thing that is feasible for you, there's no one right answer. But just choose the one thing that feels doable and start with that, and then you can start to layer in other things. And again, I also want to emphasize that if you're doing all of these things and you're still struggling, don't hesitate to go talk to your doctor about it and get a referral to a sleep specialist. We do exist, right? And we're here to help. And you know, sleep medicine is a field that, you know, is, is able to help people with a sleep issues are highly treatable,

Kerry: 32:22

hmm.

Nishi: 32:22

Don't hesitate to go and talk to somebody if you feel like you're doing all the things and nothing's working.

Kerry: 32:27

Yeah, we also at our practice, we offer health coaching and one of their coaching parameters or whatever you want to call it is sleep. So sleep, exercise, nutrition and stress. So I mean, that's certainly an option too. And then, you know, if we are needing to upgrade to anything else, I think that's helpful. Honestly, I'm not sure exactly. What each coach learns. So it would be nice for me to know that, but I think that they're, you know, perfectly capable of helping coach. And I think, like you said, keeping it simple is probably one of the best things to do to not overwhelm them. So it would change one thing until you got it down, don't move on to the next kind of thing. Did you wanna talk about sleep anxiety and what it is and how common It's.

Nishi: 33:10

Yeah, sure. Sleep anxiety. You'll see this a lot with patients who are struggling with insomnia. And it's one of these things where it starts to perpetuate the issue with insomnia. So insomnia is defined as difficulty falling asleep or staying asleep at least three nights a week for three months or longer. And almost everyone experiences some form of acute insomnia, like you know, just briefly time limited insomnia at some point in their lives, right? Like I know I have, I've had times where, you know, I just haven't, you know, I've had trouble with sleep for a variety of reasons and it's normal, right? And sleep fluctuates from night to night. So this idea that we have to get eight hours of sleep every night is, it's actually not true. But what can happen is I think that like in the sleep field, There's so much talk about sleep now on social media. There's all these influencers talking about sleep, Matt Walker's book, you know, why we sleep came out and there's a lot of interest, which is wonderful. And at the same time, I feel like sometimes it's done a disservice to people because now there's a lot of fear of, Oh my gosh, if I don't get enough sleep, I'm going to develop all these horrible health issues down the line, right? I'm going to have like cardiovascular disease and dementia and stroke and all of this stuff. And so now there's a lot of fear and anxiety that's wrapped into not getting enough sleep. So I think, you know, one, just recognizing, like, what is your relationship with sleep? How do you think about it? What's the fear around it? I'm just starting to get, you know just to tune in with yourself about that. Looking at the hyper arousal piece. That we had explored, you know, is your nervous system dysregulated. And then starting to do some myth busting around sleep as well, right? So, like, you don't have to get eight hours of sleep every night. It's okay to have nights of insomnia here and there. Actually, that means your nervous system is doing what it's supposed to do, right? We, we've developed to have insomnia now and then. It's protective, actually, right? So, kind of reframing your relationship. With that, and even just noticing the thoughts that you have first thing in the morning because I'll have patients who will, you know, they'll wake up in the morning and go, Oh my God, that was a horrible night of sleep. And now I'm not going to get through my day. And oh my gosh, what if I don't sleep again tonight? And that just feeds into the whole cycle versus reframing that to, Okay, yeah, I'm just kind of tired today. I didn't get a great night's sleep last night, but that's fine. I'll get through my day. I've done it before. I'll probably even sleep better tonight because I'll, you know, be more tired. Right? So it just takes the fear out of it. There's lots of apps out there that can actually be helpful with working through that process. Like CBTI coach is one of them. It's free. It was developed by the VA. Insomnia coach is another app developed by the VA that's free. So people can, can use that to help guide them. And then of course there's, you know, Specialists like myself who are trained in, in helping people kind of navigate this, if it feels like it's, you know, out of their hands.

Kerry: 36:07

I haven't thought about it that way. Like, oh gosh, you didn't get eight hours. Like why would anybody be, I don't know, afraid or I guess it makes sense that they were kind of perpetuated, but yeah, realizing that it's okay. Maybe I'll just get more sleep the next day is really helps. I think kind of like you said, reframe it. So that's, yeah, that's important. I've also, yeah, I've heard of those apps. I mean, I think that with the components that you're referring to, I think that the patients can realize that, okay, it's okay not to get enough, the eight hours or seven to nine hours, you know, whatever is recommended. So I think that's really helpful to know that that's okay. I don't really get anxious about that. Like if I don't get sleep, but I've never thought about it from someone who is struggling to sleep at other times. Right. So what sort of, I guess, integrative and holistic approaches do you take with helping people improve their sleep?

Nishi: 36:57

Yeah. Yeah. So, you know, I like to kind of look at the whole body, right? It's, it's kind of a whole body approach. So, you know, that's what integrative, you know, the integrative approach is really about, which is, you know, looking at the mind, looking at some of these thoughts and, and, you know other factors, the hyper arousal, the nervous system, but also exploring nutrition and gut health. And you know, you mentioned blood sugar dysregulation, because that can be a cause of Of sleep issues or sleep disturbances for people, especially if they're waking up in the middle of the night, and they're having trouble getting back to sleep and you're not really sure, you know, what's causing it. They're not necessarily waking up with, anxiety or things like that there could be something going on with blood sugar fluctuations. So that's part of the integrative approach is exploring that aspect. And then yeah, bringing in relaxation techniques. We talked a little bit about yoga. Breathwork, mindfulness those types of approaches. In some cases, supplements can be helpful. You know, I say that with a little bit of hesitation because I'm not a proponent of people relying on supplements or medications for sleep because it can actually take away your sleep confidence where now it can feel like, Oh my gosh, I didn't take my melatonin tonight. So I'm not going to be able to sleep. Or I didn't take my, you know, sleepy time cocktail or whatever it was. Excuse me. So, you know, so, so supplements can be useful in certain instances, like if someone has you know, an iron deficiency or vitamin D deficiency or things like this, these micronutrient deficiencies can also contribute to sleep quality or, restless sleep. So that's what the integrative approach is about really in a nutshell is looking at all of these different aspects.

Kerry: 38:35

Yeah, I really like your, you know, bringing in the blood sugar part of it because I'm clearly could people could be waking up with like a low blood sugar and be no idea why because they may not have the other symptoms of it, but, you know, perhaps it's from whatever they ate the night before or whatever medications they may be on. So that's a really, really important thing to be looking at as well. And then I'm not as familiar with the supplements, but I think that, you know, that could definitely be an issue too.

Nishi: 39:00

And the other aspect of this is not forgetting about sleep disorders because sometimes difficulty with sleep again, whether it's insomnia or excessive sleepiness, it could be a sign of sleep apnea, or it could be a sign of, you know, restless leg syndrome or periodic limb movement disorder, circadian rhythm disorders, or any number of other sleep disorders. And we want to make sure that we are screening for those so for, you know, for any health practitioners who are listening. That's a really important aspect before we even jump to interventions and treatments, we can use all of these other aspects of the CSH framework that we talked about. But if people are struggling, we do want to make sure that there's not an underlying sleep disorder that's being missed. And in women, sleep apnea is often missed because we often think about sleep apnea as happening in the overweight male, you know, with the 17 inch neck, the loud snoring, the gasping at night. And that is the classic archetype of sleep apnea. And yes, it can happen in, in those types of patients, but it can also happen in people who are young. It can happen in kids, it can happen in people who are, you know, fit athletes. And it's really important to know that for women all kinds of people can experience sleep apnea and it can look more subtle in some of those. Other populations. And for women in particular, Sleep apnea can look like insomnia. It can look like restless sleep. It can look like fibromyalgia Where they're just, they have aches and pains. They're fatigued. It can look like depression. And I've seen this time and again, where women get diagnosed with these other conditions. And there was. Sleep apnea underpinning a lot of those symptoms and it hadn't been addressed. So I just wanted to highlight that because it's something that I see a lot in my practice that You know, many of us might not be thinking about.

Kerry: 40:50

Do you find that sometimes you have trouble getting approval for patients who don't fit that standard criteria of sleep apnea? Like trouble getting approval for their sleep test?

Nishi: 41:00

Yeah. So yeah, for physicians, you know, if you're referring your patient for a sleep test, yeah, you just have to be very specific with what you write on that referral. So indicating that you're ruling out sleep apnea for these reasons and some of the reasons are unrefreshing sleeps, they might not have loud snoring, but unrefreshing sleep, disturbed sleep, excessive daytime sleepiness, these types of things are all symptoms so you just have to be you know, very specific about including that on the referral.

Kerry: 41:24

I remember what I was going to say earlier and it was back about the nutrition standpoint and you were talking about finding things that maybe they, shouldn't be eating perhaps or something like that that might affect their sugars and wake them up. But I was thinking also there are some sleep inducing type foods like right there are what pistachios supposed to be good and what other sort of things would you Say that is good for the evening hours or that'll help induce melatonin and things like that.

Nishi: 41:51

Yeah, yeah, it's such a great question. So, yeah, there, you know, there's some evidence for things like tart cherries, kiwis, milk that could, you know, potentially help with melatonin secretion. However, I think there's just not enough data on that to, to make a clear recommendation. And, you know, I saw one study where it's like, you have to eat so many pounds of cherries to even get like a, a natural, like detectable amount of melatonin. However, having said that there is data showing that eating high fiber foods actually increases deep sleep. Deep slow wave stage three sleep. So what I do recommend to people is before bed about an hour before bed to have a high fiber snack, especially if they are waking up in the middle of the night. And if that could be related to low blood sugar, having that high fiber snack can be really helpful. So Examples of high fiber snacks would be things like, you know, these things you just mentioned, cherries nuts you know, a handful of walnuts. It could be some vegetables and hummus if you want something more savory. An apple with nut butter. That type of thing can be helpful for stabilizing blood sugar and increasing that deep sleep. On the flip side, some studies have shown that diets that are higher in processed sugars reduce deep sleep, have a negative impact on sleep quality. Not surprising.

Kerry: 43:11

No surprise. Yeah. Yeah. I think I found myself getting nervous eating pistachios in the morning with my yogurt because I'm like, Oh no, am I going to fall asleep and pass out? Yeah. But that's good to know. And especially with the cherries, cause they're in season. So I've been having them for some snacks and I'm like, Oh gosh. Am I going to pass out? But yeah, no, I have just also, you know, heard that there's some of these things are good for sleep. And I think some of the supplements as well could you give us some examples?

Nishi: 43:40

Yeah, sure. So there is a time and place for supplements and I do use them strategically. So I'm not a fan of like just going to CVS and like buying a bunch of like, you know, Supplements sleep blends and, and testing those out because we want to focus on like the root cause of what might be going on with sleep. Having said that, though, there are some things that can be helpful. So, in some people melatonin can be helpful in certain populations, right? So I'm just kind of carefully, like, ouching that, because there are indications for it for circadian rhythm disorders. Certain medications can actually reduce the endogenous secretion of melatonin, like certain beta blockers. some SSRIs can actually do that. So in those populations, sometimes supplementing with melatonin can be helpful. But melatonin is really a, a body clock regulator, so it helps to shift the circadian rhythm. So that's it can be helpful in those cases of, like, social jet lag and the adolescence that we were talking about in a strategic Timed way. Other supplements that I often recommend include magnesium. So many of us are deficient in magnesium for a variety of reasons. And even though magnesium is not necessarily like a sleep. Aid. There's actually limited data on its use in sleep, even though it's again one of those things on social media that everyone's talking about magnesium for sleep. I'm just like blue light, but there is limited data around it. However, I have a low threshold for recommending magnesium because it has so many benefits, right? And many of us are like up to 70 percent I think of Americans are deficient in magnesium, according to some studies. So that's another one. And then a third one I'll just share is called L theanine which I might recommend sometimes for people who are struggling with anxiety and some of that hyper nervous system hyper arousal, because it can be calming And again, it's not a sleep aid, but it can support people who are struggling with anxiety, and it's usually pretty well tolerated. But of course, you know, for anyone considering taking these, do talk to your healthcare practitioner, talk to your doctor to make sure it's appropriate.

Kerry: 45:45

Yeah, absolutely want to discuss with your primary. I actually take magnesium. I'm not really sure if it's for migraines or sleep, but I don't know. I take it. It works well, but I don't have any problem sleeping as you as you might have known from this conversation. Yeah, but those are helpful. And I think I've heard of L Theanine as well. And I think Obviously melatonin, and there's always, we don't have to go into it, but I know there's a big, you know, a lot of people that use them in their kids and things like that, but it's, you know, I, I, like you mentioned earlier, like starting a medicine or even a supplement, I don't want patients to rely upon those things. So I'm like, please, let's like hold back and try some other things first before at all, you know, just boom, throwing a medicine, because they're likely not to come off of it.

Nishi: 46:31

Exactly, exactly. And then one last quick thing about supplements is quality does matter. Because sometimes people will ask me, like, what if I just get it from, you know, whatever, Walgreens, Target or whatnot. And or is it better if I get it from like, you know, one of these more expensive, like online brands. And again, the answer here is it depends, but quality does matter. So I do recommend looking out for a third party tested supplement. You can find those at Walgreens and Target. They do carry third party tested brands. I have a video on my YouTube channel about this as well, but it is important. And there was actually a study in JAMA and in the Journal of Political Sleep Medicine about melatonin quality and pretty alarming statistics there. So again, people want to look into that. You can, you can read what, what they found. But for anyone taking melatonin, especially if you're giving it to your kids be careful with the brand because just in a nutshell, some of the studies found that some of those supplements didn't even have melatonin in them they had serotonin or like Other things in them, or they had multiple fold the amount of melatonin than it said on the label, like way more than what you think you're giving to your kid. So quality does matter.

Kerry: 47:46

Yeah, that's concerning. Thank you for that advice. That's really important. Well, I think we've talked about so much. I didn't know if you wanted to tell us about your course for practitioners.

Nishi: 47:57

Sure. I can share about my course it's called the Holistic Sleep Reset, and this is open to anyone who wants to dive into holistic ways to basically, you know, optimize your sleep and you know, address some of these sleep issues that we talked about today. And it, it does bring in all these different Integrative elements that we've discussed. So the circadian rhythm, sleep drive, addressing hyper arousal with mind body practices. We talk about nutrition. We talk about bedroom optimization, creating an environment that's conducive to sleep and so on. And it's self guided and it'll walk you through the steps. So that's available to anyone called holistic sleep reset. And then I've also got a program for practitioners because as we were discussing at the beginning, most doctors only get one or two hours of sleep education, if that, during training. But, you know, as we just scratched the surface on sleep today, you can see there's so much more to learn about sleep medicine. And so I have a YouTube channel for practitioners. It's at IntraBalance, I N T R A Balance. And I have a program called the Clinical Sleep Kit. Which is so much fun. It's a membership and so we have live calls. We have case conference every month. We've got sleep experts from around the world to come on for live Q and A's and we can ask them questions. We learn together. And then there's also self guided training in that program. In addition to a discussion community. So doctors can post cases and we support each other in helping our patients with sleep.

Kerry: 49:23

That sounds so helpful. I think definitely, like you said, you're tackling a much needed area of medicine that's kind of been neglected. I love it. You kind of touched, so you have the YouTube channel, where else can people find you?

Nishi: 49:35

If people want to work with me in my private practice, I've got a practice called Pacific Integrative Psychiatry, and it's a telehealth practice and we see patients all across California, and we support people with integrative and holistic approaches to anxiety, depression, and sleep issues. So you can go to pacificintegrativepsych. com. Yeah,

Kerry: 49:54

Okay. And you're on Instagram, Facebook and all that stuff too, right? Awesome.

Nishi: 49:58

you can find me on LinkedIn.

Kerry: 50:00

Okay. Well, we'll put all that stuff in the show notes and thank you so much for all of your time today. I wasn't expecting to take so much of it, but I really appreciate it. This is great conversation. And I didn't think we'd have that much to talk about on sleep, but look at that. Okay. Well Yeah. Thank you so much. And everybody to please tune in next week. And I should say, you know, a bunch of medical clinics have been closing nearby in our area and leaving people without primary care providers. So I just do want to let patients know, tell your other friends and family, we are accepting new patients at Clearwater family medicine and allergy. So reach out to us, you know, our phone number is 727 446 1097 or find us on the internet and thank you so much for tuning in today. And please tune in next week.