Circadian science Interviews Technology

Interview With Bharath A.

Thanks so much for joining us this morning! Could you tell us a little bit about yourself and your research interests?

I am currently a theoretical and computational chronobiologist. I work in the area of circadian clocks. My PhD was in the field of wireless communications with a focus on designing new technology to provide higher rates of data transfer between phones and data stations. In a sense, cellular technology and chronobiology are connected because your cellphone’s functions depend heavily on oscillators. There is a lot to do with oscillators, amplitude, and phases, which transitions into circadian clocks and circadian rhythms. After completing my PhD in electrical engineering in the US, I relocated to Germany and explored my interest in biology, ultimately combining my knowledge of biology and engineering at a theoretical biology institute. Now, I have my one small group here at Humboldt University in Berlin.

You’ve done a lot—from blood tests for circadian rhythms to pure modeling work. What is the direction you’re most excited about in your current research? 

I am most interested in circadian medicine, (or chronomedicine). We began looking at how rhythms were generated, starting with the negative feedback loop, which was awarded the Nobel prize in 2017. In the late ‘90s and early 2000s, all the clock genes were found, and then we moved into using kinds of massive sequencing technology. We started to look at initial clock outputs, which include all the transcriptomes, and peripheral clocks in all the different tissues.

Through proteomics and metabolomics, we now have a very good idea of how rhythms and clock outputs are generated. We have also started looking at how these outputs couple with different physiological processes and how they mediate the interaction between clocks, immunity, metabolism etc. It really does seem to affect almost everything. So, I think the next natural step is to look at how we can leverage this understanding to help people improve their health. I am taking the more computational and theoretical angle, including blood tests, towards improving people’s health through circadian medicine. 

I am also involved in clinical studies that explore what has already been done in mice, although human clocks, of course, are more heterogeneous. I tend to focus on the molecular outputs of the human clock. We are trying to map out how different clocks look in peripheral tissues of specific patient groups or subpopulations. We are also currently trying to associate these data with other clinical parameters. 

I started at Arcascope about a year ago, and that’s when I learned about circadian rhythms and how it affects you day-to-day. I’m still learning, but I find the field of chronomedicine very exciting. 

What we are talking about is cutting edge in terms of medication. Even simple things, such as timing—whether to consume medicine during the day or night—have a huge impact. For example, my colleagues discovered this in a patient’s case of rheumatoid arthritis. 

The symptoms of rheumatoid arthritis are strongest early in the morning, with certain markers ascending really early in the morning, around 4:00 or 5:00 AM. So they took the standard medication, formulated a delayed-release form, and asked patients to take it at night so that the medication was released when the disease symptoms were at their highest rate. It was a very, very simple chrono-solution. I think it was published in Lancet, around eight or ten years ago in the early days of chronomedicine. Some very simple things, such as timing medication, can improve the efficacy of medicines that already exist. 

How has your work on biological rhythms changed the way you live your life day to day?

I will divide this into two parts of my life: before kids and after kids. After having kids and experiencing the coronavirus pandemic, things have become more chaotic. I have always had a fairly regular circadian lifestyle. Most of my life, I could survive with maybe six or seven hours of regular-quality sleep. I would go to bed at 9:00 PM and wake up at around 5:30 AM. And only after University, I started staying up later, typically going to bed at 11:00 PM and waking up in the morning around 6:00 AM.

I never slept in much because I was always awake once the sun was out. And now with kids, I try to work when they are asleep. So I end up staying up a lot later than I should. I know that I should not eat at night, but I still do it even though I know it’s wrong, so I will try to change that.

In fact, the funny thing was that after we created this blood test, we did the blood test on ourselves. At the time when my son was an infant, we had really crazy sleep/wake schedules. Still, when I did the blood test to determine my chronotype, it was actually the most consistent measurement of all the people we had tested. We tested at three different days and my chronotype estimate was within ten minutes of each other. So, objectively my chronotype looks pretty stable in spite of changing seasons and having to endure a crazy sleep/wake schedule.

Olivia, Arcascope’s CEO, is actually working on a blog post about how sleep regularity could be more important than sleep duration. 

Yes, possibly. As a chronologist, we do not really know how long it takes before one starts feeling the negative effects of an irregular sleep schedule. At the moment, I’m not living a chronologically good lifestyle based on what we know. At a recent meeting, we had a discussion on the effects of living against your clock and it is still unclear. 

So we talk about correlations, which is all we have. We do not really know whether it’s a consequence, which way the causality goes or whether it is bidirectional. So, it is hard to say. Essentially if we change the balance, we change the likelihood that something can go wrong.

For example, Satchin Panda, the author of The Circadian Code, discusses fasting, and emphasizes that a 12-hour fasting period at night is very important. That is one very simple takeaway from his work. I tried fasting for the longest time but it is hard, especially if you stay up quite late after dinner, then it’s hard to fast. I realize my kids can fast because they end up sleeping for 12 hours. Although, I personally know scientists in his lab who have been regularly fasting for quite some time.

And that’s an interesting thought too, is if you do eat outside of your optimal meal window, what exactly does that do?

At this point, we do not know. I do know about [timing and] caloric restriction from Joe Takahashi. It is not just about when you eat, but also how much you eat. Also, if you have a long fasting window, you probably eat less throughout the day; on average, you eat less if you have a longer fasting period. This means that for the larger part of your wake time you are not eating.

As the former public outreach fellow for SRBR, what did you learn from the experience?

The biggest takeaway is that this field, initially narrow, is now really broad. We focus on how our rhythms are generated and the outputs of the clock. Now, since we are at the point where we are looking at interactions with other systems, you can pick any other aspect of physiology and apply a clock angle. There are people working on that interface, looking at immune clocks, microbiome clocks, cancer clocks, metabolism clocks and endocrinology clocks. 

From a personal perspective, I think that this broad field is challenging because I am not a biologist with the background information that one needs to understand a lot of this. I have to know about clocks, but I have to understand some background in these other fields as well, and being in this position forced me to keep abreast of everything in these interfaces.

Through networking, I met a lot of people. I was the fellow at the beginning of the coronavirus pandemic, so I was networking while everything was digital, including our SRBR conference, which was hosted online in 2020.

It was actually surprising, people didn’t really have any baseline ideas about how this was going to work. And it worked quite well. At that point, people were quite wired and they were kind of happy to put up with anything to still function in the sciences.

One of the rewarding things, which I found out after the fact, is that a lot of people found the content produced from SRBR, which helped people create or maintain some sort of connection with the outside world since they could not travel to meetings. Everybody was more active; there were a lot of PhD students and postdocs.

How do you think we can communicate our results better as a field in general?

This is something that is close to my heart. As an SRBR public outreach fellow, my true goal was to do public outreach, although we also did a lot of “in-reach”. We did a lot of outreach within the chrono-community, which is important to other scientists who are less aware of chronobiology, similar to when you entered the industry and you were less aware of how much clocks impact other fields. 

One example was the Daylight Savings Time (DST) laws during my time as the public outreach fellow. We had a town hall and still, in spite of so much science being out there, we did not get the result that we wanted. In a sense, we got the exact opposite result. Of course, that is not purely because of the science, but communicating science is also important from that perspective. As scientists, communication is also important, since the science must be seen in the context of lifestyle, society and general health. I think we have to become better at talking to all kinds of different people. 

Sometimes that comes with being less preachy about the sciences. In the DST example, we realize that people may have other reasons for wanting something different. Everything is not just about the things that we, as chronologists, care about.

And then there are methods of communicating science. Twitter is now becoming a standard tool for communicating science at the technical level, and we are quite active on Twitter. Nowadays, I think Twitter, at least in the chronobiology field, is here to stay. If we want to reach other audiences, we obviously have to go beyond just Twitter, such as videos and visuals on TikTok.

I struggle with using videos and visuals to tell a story about chronobiology. Our research is publicly funded: the taxpayer basically funds our research. This means that we have an obligation to report our findings back to the public and help them understand and lead better lives. Scientists, who are good at writing papers, have to communicate better with the public by creating content for social media, such as this very interview, but generating content takes a lot of time and effort. 

And of course, scientists are busy people who have lots of tasks on their plates. There is a group of people who are convinced that the pluses outweigh the minuses, and that they should generate content. But then there are people who would like to generate content, but they just do not have any bandwidth or they do not really know how to do it. That’s the bottleneck, really.

I think postdocs and PhD students are much more familiar with these tools. Some of them are creative and they already generate content. Actually, during SRBR, we did this trainee session on why public outreach is important on social media and how people can get involved. 

We asked others in the chrono-community, “How has being on social media helped your science?” This question presented an interesting opportunity to network among a community of friends who maintained connections and continued to ask questions during the pandemic.

So it sounds like there are a lot of pros to being online.

One must concede that while social media is great, there are some negatives and some people do not use social media. Just talking to an audience on social media platforms is not sufficient, and one has to look at other ways to reach other groups of people, such as speaking in different spaces. If you are senior, maybe you can get interviewed by a magazine or a newspaper, for example, the New York Times. 

So a recent example is John Hogenesch’s article, which was published in the New York Times about a month ago. It is a whole write-up on health and circadian medicine, arguing the case for why we should do it.

I wanted to take the last few minutes to ask if you had any work of yours that we haven’t touched on yet that you would like to highlight.

One recent controversial (not so in my opinion) practice is the use of Venn diagrams in circadian biology studies because it tends to overestimate the impact of all interventions on the circadian clock. This study was published last year which has had a very broad impact, not just in chronobiology but in all kinds of omics studies. One of my passions is teaching. I host trainee sessions where I teach people about the analysis of circadian rhythms, and have taught at two summer schools and three trainee days. I do this regularly to help people analyze circadian rhythms, and in the end, do the science correctly.

Circadian science Interviews Sleeping troubles

Interview with Dr. Amy Bender

In a recent interview with Dr. Amy Bender, she talks about the importance of improving the sleep of professional athletes.

Could you introduce yourself and tell us a little bit about what you work on?

I’m the Director of Clinical Sleep Science at Cerebra. We’re a sleep technology company focused on better diagnosis and treatment of sleep disorders, but also focused on work to help the everyday person sleep better. I lead our research department on initiatives related to those key areas of better diagnosis and treatment of sleep disorders and sleep improvement.

What got you interested in sleep in general, but also sleep and performance?

My aunt was a sleep technologist and she invited me out to her lab. She hooked up a patient with electrodes, and showed me the translation of those physiological signals onto the screen—I was instantly hooked. After that I pretty much called every sleep lab that I could when I got back home and found a place where I could volunteer.

As it turned out, the manager of the place I was volunteering at was on the hiring committee to hire the Director of the Sleep and Performance Research Center at Washington State University. So there was kind of a collaboration there already. They were looking for a sleep technologist, then ended up hiring me as a sleep technologist. At the lab we focused on sleep deprivation and the impact on cognition and the sleep EEG. I started off there for about 4 years as the sleep technologist and was fascinated by the science so I applied to graduate school.

I ended up getting into a dual Master’s PhD program focused on experimental psychology while continuing to work at the lab. Having the sleep technologist background that I do, I wanted to focus on the impact of sleep deprivation on the EEG. After my Masters and PhD I ended up doing a postdoc at the University of Calgary where I was focused on Canadian Olympic team athletes and how to improve their sleep. Because I was a former athlete myself (I played college basketball, Ironman, I did some mountaineering as well), there was kind of a love for sports and performance already. Doing that postdoc at the University of Calgary was like a combination of both of my passions. Since then I have worked with a number of college athletes, professional athletes, and Olympic athletes.

It seems like the importance of sleep for sports performance is getting more recognition these days. What shifts in perception have you seen in your career?

Well, I see more of an emphasis on sleep in sports teams for sure. Previously, the coach would only focus on things that they had control over with their players while at the facility. Things like sport-specific skills, conditioning, and strength. This has since expanded into nutrition on and off the field, sports psychology, and sleep. Once we started to realize how important sleep was for performance, I think the teams and athletes started listening. We still do have a long way to go, there’s only a handful of us out there working with teams and elite athletes and so I think it can certainly grow a lot more.

For example, Dr. Cheri Mah’s study on sleep extension in Stanford basketball players and how that impacted reaction time, mood, and sprint times—I mean people started to listen and I think we’re finally getting there. If a team or an athlete isn’t thinking about sleep, then they’re really missing out on a huge area of performance.

Our CEO actually wrote a blog post about this during the Olympics. Discussing how athletes can entrain to their new time zone and for their specific competition time.

Oh absolutely that is important, I recently went on a trip overseas, and it’s apparent. I tried to do all that I could to shift my rhythms earlier (I was traveling to Europe) so I was trying to get lots of light in the morning, get up earlier, block light at night, go to bed early, you know—just trying to shift my rhythms about three days before the trip. Even doing all that, being the sleep scientist that I am, I still had jet lag upon arrival. It was a quicker recovery, but still: people need to be thinking about If they’re traveling across time zones. They may bank on the fact that “I’ll get there a week ahead of time and I’ll be adjusted by the time the competition starts”, but I think the training leading into that competition is also important for being fresh and ready and alert. It’s definitely a factor for teams and athletes traveling across multiple time zones, and there’s a lot they can do ahead of time to help prepare for that.

We’re betting people ask you for sleep tips pretty regularly. Is there anything where you’re like “people still haven’t realized how big an impact this could have for them”?

You all are a circadian optimization company, and so one of the things is that light is so important. For example, I’m in my office right now in low light, it’s only between 100 and 200 lux, and so I think it’s important for people to understand that the indoor environment isn’t necessarily optimized for circadian optimization. Trying to get outside in the morning is key for me, even on a cloudy day where light could be up to 13,000 lux or so.

It’s important for people to get outside light and go on a walk in the morning to help entrain their circadian rhythms to be more on that normal schedule. Many people don’t realize it, they think that their office environment is perfect for light. But getting the right amount at the right time, starting in the morning, is very important. Then also trying to dim the lights at night and maybe wear blue light blocking glasses in the evening are good tips for people to follow.

There’s been some work looking at office lighting, having bright white light in the morning and then as the evening approaches kind of transitioning to more of that orange kind of sunset lighting. And they do find improvements in sleep, in performance, and even mood.

Like you mentioned, we’re a circadian rhythms company first and foremost, so we gotta ask: What do you think the future holds for circadian rhythms research in the world of elite performance? How about just overall health?

I think there’s a lot to uncover here, and in particular I’m really interested in the individual, their own chronotype, their own circadian rhythm, and optimizing training times based on when they would perform the best. For example, if they’re more of an early bird but they have evening competition, how can we optimize our circadian rhythms to shift more towards an optimal performance time in the evening? I think this is a fruitful area that has a lot to be explored, and there are hints of it in the research right now. I think we could do a lot more to shift circadian rhythms for optimal performance at a certain time.

A while back, there was a realization that strength and conditioning is important, and so sports teams would add a strength coach. Then there was a realization that nutrition is also important, so they would add a nutritionist to the team. Now (potentially) I think that you might see more sleep coaches helping out teams. There’s a lot of work out there that we aren’t necessarily taking advantage of and I think that could be an area where maybe more sleep coaches will pop-up for different teams and different athletes.

Any research you’re excited about or want to highlight?

At Cerebra, we’re working on developing a kind of a miniature EEG wearable device that you could potentially wear on the forehead or even measuring in-ear EEG with one of our partners that we are working with. We want to pair that with an app to be able to figure out for the individual what their triggers are for sleep quality. We have a way to measure sleep quality using ORP (which is a metric of sleep depth which micro-analyses the EEG). We did a study recently where we had 20 people do 20 nights with our current device while tracking their lifestyle factors such as, caffeine, exercise, alcohol use, and how much they got outside. We’re really seeing some interesting results with some of those lifestyle factors and how that impacts sleep quality, and also how that impacts next day performance. Additionally, we did a reaction time test for all those individuals, we’re just finding some really interesting results and I think we want to go way beyond the “general sleep hygiene” advice for people and make it more personal and individualized.

For example, I might be a high or a fast metabolizer of caffeine, and so a coffee at 1 p.m. won’t necessarily impact my sleep quality vs someone who may be more of a slow metabolizer – where it would impact their sleep quality. I think it’s really exciting for us to really try and personalize sleep optimization for different individuals.

Actually, I was listening to a recent podcast that Olivia (CEO of Arcascope) was a guest on, and she mentioned that sleep at night starts with what you do during the day. A lot of these activities, stressors, or anxiety that you experience during the day can then impact your sleep quality at night.

Actually, before I started working at Arcascope, I had no idea that what I did during the day impacted my ability to fall asleep and stay asleep. Having experienced sleeping troubles throughout my life, I wish I had this knowledge sooner!

For sure, that brings up an important point. If you are struggling with your sleep, and you have tried different things but it doesn’t seem to impact your sleep quality, try and get help from a sleep professional. If you’ve been struggling multiple times for weeks you’ve tried everything, don’t try and solve it on your own but really try and reach out to sleep professionals who can help.

Circadian science Interviews Shift Work Sleeping troubles

Interview with Dr. Louise O’Brien

Thanks for letting us interview you, Dr. O’Brien. Would you mind introducing yourself to our audience—where do you work, what do you do?

I’m Louise O’Brien, an Associate Professor at the Division of Sleep Medicine, Department of Neurology, at the University of Michigan. My work focuses mostly on sleep disruption in pregnant women and its consequences. I’m also interested in treatments and therapies available to intervene to improve the health of women and babies.

Your work largely centers around sleep and its connections to pregnancy and maternal health. What led you to this field of study?

That’s a great question. Going back a long time ago when I was a graduate student, I was really interested in SIDS (Sudden Infant Death Syndrome) and why seemingly healthy babies died suddenly at night. So, I was spending a lot of time monitoring babies overnight to understand what was going on physiologically. That led me to really want to understand more about what happens during sleep, because I realized I’m doing all this nocturnal monitoring, and I really don’t know that much about sleep. That brought me to the United States—to become trained in sleep.

What are some of the things that are really well-known about how sleep affects pregnancy?

I think most pregnant women know that sleep can be quite disrupted during pregnancy. Healthcare professionals can dismiss this as normal, or it’s the body’s way of getting ready for a baby, etc. But I think we’re now learning that certain types of sleep disruption, such as frequent snoring or obstructive sleep apnea can actually lead to poor health outcomes for mom and baby. Poor maternal sleep can lead to high blood pressure or diabetes in the mom, and can also result in poor fetal growth, preterm birth, even an increase in c-section deliveries.

We are learning more and more with the work that we do. For instance, in recent years we’re learning that sleep behaviors, like sleeping on your back, appear to be related to poor outcomes such as stillbirth. A woman who has a stillbirth in late pregnancy has been shown to be more than twice as likely to have fallen asleep on their back. So, this is a relatively new area, and an area that we’re very interested in. I think that behaviors such as sleep position are particularly interesting to me because they can be changed. And If we can change behaviors, that offers an opportunity for intervention that could potentially reduce poor outcomes.

What are some of the current research questions around sleep, circadian rhythms, and pregnancy that are most exciting to you?

I’m becoming really interested in the timing of sleep. A lot of my previous research has been on sleep disorders, like obstructive sleep apnea, which is a medical condition that can be treated. We all sleep, but we don’t all have a sleep disorder. And so, what we’re learning from the general non-pregnant population is, even if we get sufficient sleep (7-8 hours as an adult), if that sleep is mistimed against your body’s natural rhythm there appears to be an increase in blood pressure. So, I’m interested to take those findings to the pregnancy population and to see if mistiming sleep during a critical developmental window for a fetus has adverse consequences which impact the health of the mom , and also the health of the baby. Because we know that what goes on in utero can sometimes have long term effects decades later, potentially even transgenerational, this is an important area that we really don’t know anything about. So the timing of sleep is something I’m really getting interested in. Because, again, we can change it.

The obvious place we see mistimed sleep is in shift workers, but they may not be able to change so easily because they’re working shifts, and they’re working against their body’s natural rhythm. That’s an extreme example, but we know that miscarriage is higher in shift workers than non-shift workers. So the question is, what is mistimed sleep against our body’s natural rhythm really doing?

Since we’re a company that does wearable analytics: What’s the current state-of-the-art for wearable tracking during pregnancy?

It’s not very good. I think with lots of wearables out there that claim to be able to track your sleep, the reality is that none of them are really validated against the gold standard- which is an overnight sleep study. There is an algorithm that has been validated against polysomnography, a type of sleep study, but none have been validated in pregnant women. So, we just really don’t know. While there are lots of things out there that claim to track your sleep, there is nothing out there that tracks it accurately in pregnant women. There is definitely an opportunity for growth in this area, absolutely. Wearables let you look in your app, and it says “REM sleep or deep sleep”, but how accurate is that? We really do not know. So many people have wearables, and I think if we can somehow harness that technology and validate it, then we have a real opportunity to see how sleep across gestation impacts maternal and fetal health. Now this is a window of opportunity. We should be doing this now, because we could then make a huge difference to the lives of mothers and babies if we just had this data.

People sometimes use sleep and circadian rhythms interchangeably, even though they’re not the same. Are there any circadian-specific angles to pregnancy and delivery outcomes that you think are particularly important to call attention to?

I would go back to this idea of mistimed sleep. You can get sufficient sleep and still have poor outcomes, potentially if your sleep is mistimed. We’re learning that in the nonpregnant population now. So, the timing of when we sleep is really important. We already know that getting insufficient sleep is bad for us, but we just assume if we get 7-8 hours of sleep we must be fine. But, if we mistime that, then maybe we’re NOT so fine. I think this is a really interesting area, and how does that relate to pregnancy? We just don’t know, the data is not there. But, I think that this is going to be the next niche area.

Some literature that’s coming out now is adding another layer on top of that. For instance, our diet—WHEN we eat. What’s the impact of eating late at night or mistiming our eating, and how does that affect pregnancy? I think this is a more complicated area that’s going to get a lot of work in the next decade. This is where the field is going to go, and I would like to think that we would be in there somewhere you know, making some inroads into this really important area. I think it’s crucial that we understand what’s going on with our timing, and our eating, and how that’s impacting our own health and the health of that developing baby. Timing is everything, right?

Anything else you’d like to highlight, from your own work, or as an area that needs more attention?

One of the things I would like to mention is: how does sleep play into disparity in healthcare and disparities in outcomes? So for instance, we know that minority women have worse outcomes than caucasian women, we also know that minorities in general tend to have poorer sleep. How does this whole sleep, pregnancy, and disparities play together? That’s a little bit unknown at this point. This is another area that I think is really important—is there a role for sleep and addressing sleep issues in being able to improve outcomes for minority pregnant women? Outside of pregnancy, we know that minorities in general have worse sleep than caucasians, especially Black women. We also know that Black women have worse pregnancy outcomes. For instance, they have double the risk of having growth-restricted babies, and also have higher risk of preterm birth. Nobody’s really looked at pulling sleep into that. We’re looking at two parallel angles, and what I think we need to do is bring these things together to see if there is a role for sleep in these poor outcomes. Because if there is, then we can intervene.

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Circadian science Interviews Sleeping troubles Technology

Interview with Dr. Cathy Goldstein

We sat down to talk with Dr. Goldstein on what she sees as the future of wearables in the sleep clinic. Enjoy!

Thank you for taking the time to meet with me today! Could you take a minute to introduce yourself and say a little about what your job is?

Cathy Goldstein, MD. I’m a neurologist, Associate Professor of Neurology here at Michigan Medicine, and my clinical practice is entirely in sleep medicine.

You’ve done work with [Arcascope CEO] Olivia on wearables, and you’re heavily involved in the AASM and consumer sleep technologies. Where do things stand today for consumer sleep technology and wearables, and where do they need to go?

These devices really started becoming prominent about 8 years ago. I remember I was right out of my fellowship at that time, and I thought, wow, these will be so awesome for when a patient sees me in the clinic: I have all these questions about their sleep and sleep timing, and how they sleep on the weekdays vs weekends vs vacation, and they’re in the position of having to try and remember what their problems have been over the long time they’ve been waiting to see me.

And the problem with a sleep log [that someone fills out manually] is that it’s hard to keep up with every day. In this busy world, you need more of a passive degree of tracking, particularly over time. So when wearables came out I was like, wow, you know, wouldn’t it be cool if when the patient shows up I can just take a look at their data in the last six months and see their sleep patterns.

The problem as far as adoption has gone, is that we don’t know how accurate they are at tracking sleep. So, there’s a medical grade version of consumer trackers called “actigraphy”, although they’re not completely accurate, we KNOW how accurate they are. And so, particularly in science and medicine, what is known is better and less scary—even if the performance isn’t great— than the unknown.

There are a lot of unknowns in regard to consumer-targeted sleep tracking because there’s not a lot of peer-reviewed literature about the performance of these. It’s growing, but even when the accuracy does get reported in a paper, oftentimes the algorithms change with updates, or the hardware changes a little bit with each iteration. The big thing is—we just don’t know. And that’s really prevented adoption in research and clinical practice, unfortunately.

What are the biggest misconceptions about sleep wearables that you see out in the world?

The biggest misconception is that they’re totally inaccurate, that they’re inferior to actigraphy for some reason, because the data that we have so far doesn’t necessarily suggest that. For many of these devices, we just don’t know, but the ones that we do know about appear to perform similarly.

I’d say the other misconception is people say, “My watch tracks my sleep.” Your watch doesn’t track sleep: your watch tracks your heart rate or your pulse, and your watch tracks movement. And then, math estimates your sleep from that device. So, that’s a big misconception of people telling me in the clinic, “My device is telling me I don’t have REM, so my sleep is really bad.” Sleep stages like REM, NREM are polysomnography EEG constructs. So, to use a consumer wearable sleep tracker’s components of dream sleep, light sleep, deep sleep, interchangeably with PSG-defined states— we’re just not there yet in my opinion.

I do think the estimates are getting better, and they do use properties of heart rate variability that we know change in the different sleep stages, but still, those [stages] are defined by brainwaves and eye movements. So, it’s very hard to recapitulate that. The question is, “Do we even need to track that on a daily basis?” What we’re really looking for, and what the clinical and research world wants, is to track on a longitudinal basis— objectively— just sleep-wake patterns day to day.

How do sleep trackers fit in with sleep clinics right now?

People sometimes think that doctors just don’t want to look at sleep wearable data because we don’t like it—that’s not true. A lot of us love seeing this data and love seeing sleep patterns over time, particularly if a patient can tell me “Hey you know, you treated my sleep apnea with this CPAP machine, and look at the change in my wearable tracked sleep.” One of the massive problems, though, is that clinical practices are really, really busy. We have a lot of patients that need help, and we need to give everybody high-quality care.

This means we have a high volume of work and most of our work takes place through something called the Electronic Health Record, and at this point, there is no real way to interface the data that comes from consumer wearable devices with that Electronic Health Record. So, we really don’t have a good way of integrating any of this into our clinical practice. It’s not that we are absolutely opposed to using this as an adjunct, particularly the ones that have some idea about performance, but we don’t really have a way of getting it in there to make it an easy part of our workflow. Patients will send me screenshots, or they will show me their app in the clinic.

I think medicine moves slower than consumer-geared technologies for a multitude of reasons, including security issues, but I do think that one day we will get there. And again, we’re not using these as diagnostic tools; we’re using them as an adjunct to our clinical decision-making. So, as long as they are reasonably accurate, and we overall know how they work, I think a lot of doctors would like to adapt them into their practice as long as we have a way of seamlessly integrating that data into our workflow.

Do you think we’re going to see circadian rhythms enter the clinic more in the near future?

Yeah, and what I would hope is that they don’t just enter the sleep clinic, but they enter the wellness and general health area as well. I think a lot of us are doing all of our body systems a big disservice by living in desynchrony with both our central clock and peripheral clocks.

When my friends and family ask, “What are some of the best things I can do for my sleep and circadian health?” I say “Wake up at the same time every single day.” That’s going to entrain your circadian phase. And hopefully, you’re eating in line with that (and you’re not eating when you’re supposed to be asleep), and when you’re getting light when you wake up. We are all undergoing mild degrees of circadian disruption by varying our wake-up time and getting as much light at night as we are.

Definitely. Especially with screens. I was one of the people who thought my phone screen couldn’t possibly affect my quality of sleep.

Exactly! And I think people are becoming more aware. I mean when you talk about intermittent fasting, that’s kind of a chronotherapeutic measure. It’s so simple, but people get so excited about it. It’s like yeah, don’t eat when your body is biologically prepared to be asleep.

You’re right that it’s incredibly simple, and I think people really respond to small changes that make a big effect on their health and wellness.

And it’s not magical, it’s timing. It’s literally all about timing.

What do you believe the future holds for sleep technology? What are you most excited about?

I’m just hopeful for a day where we change the way clinical evaluation works now, where a patient might be waiting for me to see them for months and months, and then I see them, give them instructions, send them home with sleep logs so I can see how they’re doing, and tell them to come back to the clinic in 6 months because I’m booked out I can’t see them sooner.

I want to get to a point where I see them, and at that initial point of care I know what their last 6 months of sleep looked like, and then I can come up with an intervention that’s precise for them and that’s also adaptive based on how their sleep looks in response to intervention.

Then possibly, when they do go home, we can change that intervention, maybe in an automated way, maybe with me being able to interact with an app, whatever it may be – but instead of writing down instructions and giving people medications, we’re using the mobile application as a prescription to really make patient-specific interventions that are based on wearable data.

So, it’s important to make it less labor-intensive for the patient because then it’s less likely to be done correctly or be done at all.

Exactly, we’re talking about behavior change here. That’s one of the cornerstones of so many diseases we take care of in medicine: they’re due to things that with behavior change could be different, and behavior change is hard. One of the behaviors that we’re really, really good at in current society is working with our devices and our apps. So, I think it’s just a no-brainer as far as delivery goes, I think it’s really time to make this stuff an adjunct and a helper in healthcare.

What have you seen in the clinic in the age of COVID?

I’ve seen a dichotomy. I mean I don’t think we’ve ever collectively (people my age, middle age, most of my patients) have gone through a stressor like this. So, there are quite a few people who had significant insomnia; there are people that had COVID that had major health disruptions during and following that, including fatigue during the day. Then there are people who actually had marked improvements in their sleep because they can sleep according to their clock, and they have more time due to less commute and so they can extend their sleep a bit.

There have actually been patients who go off alertness-promoting medications, and are a bit happier with their sleep. There was a great article about a gentleman who had always felt confined to the service industry because he was a night owl. He was always kind of stuck, like a bartender/server, and during COVID (because hours were more flexible with work from home), he was able to go into other industries and have regular hours at the time he selected, and have a more stable work path. Which is what he wanted. You know, we shouldn’t chronotype shame people. Just because you’re biologically late you shouldn’t be at a disadvantage in life, and that’s helped a lot of people’s sleep.

It’s nice to hear some good news come out of the year 2020. That’s all the questions I had lined up, but do you have anything you would like to add?

I think there’s also, what can wearables NOT do. So, we don’t know how accurate the oximetry is yet, we don’t use this as a way to diagnose sleep apnea, I don’t think that sleep staging is something we should rely on. It’s that sleep disordered breathing, is not really something we have not been able to pick up yet, so when people have some episodes of sleep snoring or gasping, feeling sleepy during the day – even if your wearable says you sleep great, that is a limitation and you should still see your doctor.

So, if you feel something isn’t right, it’s best to go in and talk to your doctor.

Exactly, trust your body. The manifestation of diseases is how you feel, not just how your numbers are.

Circadian science Interviews Lighting Sleeping troubles

(Lack of) Light at the End of the Tunnel

A sleep story

Today we had the pleasure of interviewing one of our own, Eric. He’s a skilled mathematician and AWS developer here at Arcascope. Everyone has their own unique experience when it comes to catching Zzz’s, or in Eric’s case, NOT doing that. We wanted to chat with him and learn more about these troubles and, more importantly, how he overcame him.

Let’s jump right in. How has your sleep been lately?

“Right now, my sleep schedule is pretty good, but this has changed over time and pretty dramatically over the last eight months or so. I feel like I have finally figured out some other things that my body needs for me to be able to fall asleep quickly. I have struggled to sleep for a lot of my life. I break it down to two components: One, once I was asleep, staying asleep, and two, also falling asleep to begin with– this has been the hardest part for me. I’m still not to the point where I can fall asleep straight away, but I have gotten it to under an hour.”

So, your sleep has improved recently?

“Yes, It’s a lot better. Much more regular in schedule, and it’s pretty easy to fall asleep and stay asleep throughout the night.”

You mentioned having trouble falling asleep your whole life. What has it been like, and what are the specific problems you’ve had?