In this extract from his new book, Dr Michael Mosley writes of learning to live with insomnia and the links between snoring, sleep apnoea and being overweight.
My idea of a great night’s sleep is to go to bed around 11pm, fall asleep within a few minutes and then wake up, refreshed, at about 7am, without the need for an alarm clock. That would be lovely. It is what used to happen. It hardly ever happens now.
I have no problem getting to bed and falling asleep, but I almost always wake up in the middle of the night, and sometimes find it hard to get back to sleep. In this respect, I am a classic insomniac.
There are other types of insomnia: not being able to get to sleep is quite common, as is waking up early in the morning. But the most common form is waking in the middle of the night, particularly as we get older. This is partly because our sleep gets lighter as we age, but also because of things like having a full bladder and feeling the need to go to the toilet.
I used to get quite worked up about this. I resented the fact that no matter how tired I was, I’d wake up four and a half hours after going to sleep (normally around 3.30am). I would go to the loo, get back into bed and then just lie there, for what felt like hours, worrying about not being able to get back to sleep, and worrying about how tired I would feel in the morning. Finally, I’d drift off, only to be dragged awake again by the alarm clock at 7am.
Then, a few years ago, while researching a documentary about life in Victorian slums, I interviewed Roger Ekirch, a professor of history at Virginia Tech in the US. He told me that my pattern – falling asleep, waking for a while, then falling asleep again – was how many people slept in pre-industrial times. Apparently, people would go to bed around 9pm, sleep for about five hours, then get up at about 2am. They would do household chores, visit friends or “enjoy a bit of intimacy”, before heading to bed again for a “second sleep”. Ekirch believes the pressures of the industrial age and the arrival of electric lights changed all that; sleeping continuously became the new normal. And, as the practice of sleeping continuously became more widespread, the idea of a “first” and “second” sleep faded from public consciousness. Even napping, which can be hugely beneficial, and which used to be very common in hot countries, has largely been abandoned.
To support his claims that biphasic sleeping (sleeping in two blocks) has deep roots, Ekirch pointed me towards research done by Dr Thomas Wehr, a psychiatrist at the [US] National Institute of Mental Health. In the early 1990s, Wehr conducted an experiment in which he persuaded a group of healthy volunteers to spend a month in a lab, where it was pitch black for 14 hours of the day.
By the end of the experiment, the volunteers were sleeping an average of eight hours a night, but not in one block. Instead, they slept for three to five hours, woke for an hour or two, then fell back asleep for a second block of three to five hours.
Carol Worthman, an anthropologist at Emory University in Atlanta, thinks there may be something in Ekirch’s claims. She has studied the sleep patterns of hunter-gatherers who follow a pre-industrial way of life. She says that interrupted or polyphasic sleep is quite normal among them. In many of the tribes she has studied, she has found around one in four people are up and active at any given point in the night. She thinks there may be an evolutionary advantage to this, because when our remote ancestors lived out in the open, it would have been important that at least some of the tribe were awake, alert and looking out for predators.
If, like me, you often find yourself awake in the middle of the night, you can console yourself with the thought that humans have probably been doing this for thousands of years. Buoyed by these discoveries, I decided that rather than fight my “old-fashioned” sleeping patterns, I’d work with them. So, these days I accept that I will probably wake at about 3am and plan accordingly. If I have an early start, then I aim to be in bed by 10.30pm. This gives me a roughly four-and-a-half-hour “first sleep”.
When I wake around 3am, rather than lie there fretting, I get up and go to another room, where I listen to music, meditate or read a really boring book. I keep a special collection of books for this purpose. When I start to feel sleepy, which is normally after about 40 minutes, I go back to bed for three or so hours of “second” sleep.
Between my first and second sleep, I take care to avoid doing anything exciting or stimulating. If you are awake in the night, your goal should be to bore your brain into going back to sleep. Since I have, slightly reluctantly, accepted that I am unlikely to return to sleeping for a whole night without a break, I’ve felt more rested, less stressed and much less likely to nod off during the day. Try it for yourself, and let me know how you get on.
High-decibel snoring
Along with having a full bladder, one of the main reasons people sleep badly is that they or their partner snore. I come from a long line of snorers. My father used to snore really, really loudly, like someone sawing logs. It was loud enough to be heard on the other side of the house.
I also used to snore at an incredible volume; in fact, my wife said that when we lived in London, I snored so loudly that I drowned out the sound of the metal beer barrels being delivered to the pub opposite first thing in the morning.
Although the caricature of a snorer is a fat, middle-aged man, women also snore. A few years ago, British newspapers outed a grandmother of four as “one of Britain’s loudest snorers”. She was recorded snoring at a window-rattling 112 decibels, which meant her snoring was louder than the noise made by a low-flying jet.
According to the papers, it was loud enough to drown out a “diesel truck, farm tractor or speeding express train”. Apparently, her husband coped by sleeping in the spare room and burying his head in a pillow.
I don’t know if this was her problem, but the main reason most people snore is that they are overweight. If you are a woman with a neck size over 16 inches (41cm), or a man with a neck size over 17 inches (43cm), you are almost certainly a snorer.
As we get older and fatter, we snore more. That’s because our throat gets narrower, our throat muscles get weaker and our uvula, which is that finger-like bit of tissue that hangs down at the back of our throat, gets floppier. All these changes mean that when we breathe in, the air can’t move freely through our nose and throat and into our lungs. Instead, the incoming air makes the surrounding tissues vibrate, which produces that horrendous snoring noise.
Snoring and sleep apnoea
As well as being annoying, snoring can be a sign of obstructive sleep apnoea (OSA), which is much more worrying. OSA occurs when muscles at the back of the throat relax and temporarily restrict or block airflow as you sleep, which leads to falling blood oxygen levels. This, combined with an increase in blood pressure, puts you at increased risk of having a heart attack. It can kill you. The actress Carrie Fisher, famous as Princess Leia in Star Wars, died from a heart attack at the age of 60 while on a plane. The coroner said that the main contributory factors were untreated sleep apnoea and a build-up of fatty tissue on the walls of her arteries.
An awful lot of people with sleep apnoea go untreated because they think it is just snoring and that snoring is harmless.
A couple of years ago, I was on a train when an overweight middle-aged man called George introduced himself. He knew I wrote diet books, but was keen to point out that he didn’t believe in them and he certainly didn’t need to diet.
I asked George if he had any trouble sleeping, and he admitted that he felt tired all the time. He also said he snored loudly, particularly after a few drinks, and that his wife had told him there were times during the night when he stopped breathing. He said he wasn’t worried by this, but I was, particularly when he told me that he was a long-distance lorry driver and kept himself awake with energy drinks. I suggested he get his wife to stay up for an hour or two to count how many times he stopped breathing. “Stopping breathing” means not breathing for 10 seconds or longer. Other things to look out for in someone with sleep apnoea are regular gasping, snorting or choking noises, hypersomnia (excessive daytime sleepiness), and lack of interest in sex.
There are apps you can download, like Snore Control and SnoreLab, which warn you that you might have sleep apnoea. Once you have downloaded one of these apps, you just leave your smartphone by your bed. The app can, apparently, detect when you are snoring loudly, if you wake up gasping for air, or if you wake up making choking sounds.
If the app tells you there is something wrong, or if you are waking up a lot in the night and your partner says you are making gasping, snorting or choking noises, then do see your doctor.
Other warning signs are waking up with a headache, feeling very tired during the day, and finding it hard to concentrate. This is something that is really worth taking seriously because as well as leaving you feeling exhausted, it greatly increases your risk of heart attack and stroke. Sleep apnoea is strongly linked to insomnia, and if you have both (it is called COMISA), then the health risks are higher than having either condition alone.
OSA affects around one in four men and one in 10 women. Unfortunately, it is particularly common in truck drivers, who tend to be overweight because they spend a lot of their working lives sitting on their bottoms eating junk. A recent study of 905 Italian truck drivers found that about half suffered from a sleep-related breathing problem, making them dangerously prone to falling asleep at the wheel. I pointed out to George that having untreated OSA doubled his risk of sudden death. The fact that he was starving his brain of oxygen every night also increased his risk of Alzheimer’s and dementia. He looked pensive.
I explained that the best way to cure his snoring and his sleep apnoea was to lose weight, fast. The reason I used to snore so loudly was because I had a 17-inch (43cm) neck. When I put myself on the 5:2 diet, back in 2012, and lost 20lb (9kg), I also lost an inch (about 2.5cm) of fat around my neck. I completely stopped snoring and our house was finally at peace.
I suggested to George that he find out more about the advantages of rapid weight loss and how to do it safely. He said he would think about it. I like to think he followed through.
4 Weeks to Better Sleep: A Life-changing Plan for Deep Sleep, Improved Brain Function and Feeling Great, by Dr Michael Mosley (Simon & Schuster, RRP $38.99). To read more about the book, go here.