Building a Sleep Health Plan for Athletes with Dr. Jesse Cook. EP#581

(upbeat music) Greetings and welcome to the latest edition of the AMSSM Sports Medcast. I'm your host today, Dr. Devon McVaddon, and I'm thrilled to be joined by our guest, Dr. Jesse Cook, who I will allow to introduce himself to discuss the topic of sleep and sleep programming. Jesse, could you tell the audience a little bit about yourself and your background? - Sure, absolutely Devon, and I first must say it's truly an honor and a privilege to be here, not just with the podcast, but at the American Medical Society for Sports Medicine Conference. I mean, honestly, I've been to many conferences around the world, and this one is really unique and special. I've really enjoyed the camaraderie and the qualities of the experience, so fantastic there, and thank you for the invitation to the platform as well. As he said, my name is Dr. Jesse Cook, PhDs in clinical psychology, which I acquired from the University of Wisconsin in Madison. I'm currently a post-doctoral fellow at University of Wisconsin Madison in the School of Medicine and Public Health and the Department of Psychiatry. That's a mouthful. And generally speaking, my training in science and practice has been grounded at the intersection of sleep and mental health, and I really fell in love with sleep in 2011, but basically this essential behavior that we all do that's much more complicated than just going behind a closed door and waking up feeling refreshed for eight hours. It just captivated me. And over the last seven to eight years, I've really been able to kind of merge my passions between sleep and sport, and a lot of my social media handles I got in early, and I've got the sleep and sports title, so it works pretty well. Nice. Yeah, no, I'm really thrilled about that at this point. Population of athletes who are trying to maximize elite performance, achieve at the highest stage, are often the most vulnerable at times to sleep and circadian issues. And I know there's been increased awareness over that time period to kind of support, and there's still a lot to be done. So I'm hopeful to kind of continue to champion that perspective in both science and practice. Awesome. Well, thank you for the work you're doing. I was skimming through the lectures and trying to find people that I was interested in recording with, and the thing that caught my eye about your session is that you spoke about sleep programming. And obviously with our strength coaches, we're all familiar with programming, athletics, and performance and training. But I've never heard sleep described in that manner before, and I think it makes a lot of intuitive sense, but it's kind of a novel way to approach it from my perspective. So could you describe to us where you came up with that and what sleep programming is to you and how you utilize it? Yeah, and I think first what I want to start with is just kind of honoring that sleep is this critical essential behavior, right? That impacts all aspects of life, and that speaks to its importance and the relationship that we want to have with sleep, where it's not something that should be an afterthought, right? It's a priority. And so when I think about kind of building a sleep health program or a sleep in circadian health program for athletes, it's really thinking about our relationship with sleep, and that it's not just something we're sticking in at the end, or monitoring for issues across the board as we go through different periods of time, whether that be training or competition seasons, travel, finding the unique factors and barriers that are negatively influencing our sleep that athlete you're working with. And then finding a way to triage to specialists and when necessary to support sleep disorders and greater sleep concerns. So bringing in this ecosystem of support to collaboratively and cohesively support an athlete's sleep. So I think about program per se as something that is living and occurs dynamically and fluidly across a calendar year, rather than just something that occurs episodically. So it really just becomes a focus that has multiple components to it. Everybody has to fit sleep into the context of their daily lives. And I think that's where the challenge comes in. I think everybody has good intentions in terms of approaching sleep and getting the proper amount of sleep. But then they have children or they have to travel across multiple time zones and different things kind of get in the way. You talked about prioritizing sleep. How do you help support the athlete in understanding the importance of sleep when they may foresee that training is more important or family time or other things? How do you help teach them the importance of this to support their performance? Brilliant question. And a fundamentally critical question when focusing on not just with athletes but any individual, myself included, why is sleep important to me? And it's going to change at various points in my life to what is speaking to me to put down the phone an hour and a half before bed and really trying to be mindful of different factors that are positively and negatively influencing my sleep. So I think really anchoring it to finding this personalized wife or an athlete, unfortunately, to your point, there's only a limit amount of time and a day. And unfortunately in my training, I haven't learned how to get more hours in a day. So we still have this set amount of time. And when we start educating on sleep, we understand that there is a sleep need for each person a duration in each night. And that's going to vary between people and within people. Night to night, you may have a different sleep need. But generally speaking, we all have kind of an amount of sleep that we feel our best with. And mine is somewhere around 7 1/2 hours for young adults that's usually between 7 to 9 hours for older adults that's usually between 7 and 8 hours. But there's going to be a lot of variation there. And so I think understanding that that amount of time is required and even a little bit more so because sleep's a process, right? We don't just fall asleep immediately or if that's the case, there's often indicators that there might be a sleep disorder going on or chronic insufficient sleep. So there needs to be some time budgeted to falling asleep and waking up during the night's normal. So if I need 7 1/2 hours of sleep, that means that I probably need about an 8 2, kind of 8 1/4 window of opportunity. So just starting with that discussion to recognize that, oh man, for me to kind of have the relationship I want with sleep, that's probably beneficial for me for not just short term functioning, but long term. It's about a third of my day in sitting with that. And then trying to figure out, okay, so if this is that important for all these different factors, how am I going to motivate myself to make this change and really anchor it at the core of my schedule and reverse engineer things around that? If I'm working with a younger athlete per se, it may be about performance, right? It might be you're trying to get from 95 miles per hour to 97 or you want to be a little bit less anxious over that three foot put as you're trying to win a championship, those aspects we may speak to. With older adults, it may be about recovery or preserving kind of the athletic career and lifespan there. And thinking about athletes outside of just sport too, and just the well-being, there's life outside of sport. And so whether it becomes being a better partner, being less irritable, our relationships with people, our ability to maintain cognitive health across the lifespan. So it's really about trying to find that signal that speaks to that individual. And I think as providers often do so well, there's an art to that. And the first thing you bring up, it may not be that answer, but sometimes you see that spark in somebody's eye or you hear something in that story. And that's where you kind of dive in. - That's great. So you referenced finding the individual sleep need as a primary care doc and kind of a beginner in looking at sleep scientifically. How do I determine my patient's individual sleep need? And is that something that we do through tech and wearables? Or is it something that we can figure out just with a sleep log and tracking how they're feeling day to day? - As psychologists tend to respond, I've been trained by many of them, it depends. And so often this is done just with a single question, for what duration of sleep do you need to feel your best? And that's usually pretty telling, truly. Now at the same time, it's limited. As we're not, at times the best kind of retrospective reporters, and often there's an educational gap when we start about how much time I'm actually spending in bed versus how much time I'm actually sleeping. So sometimes that first response will actually just reflect the time they're spending in bed and nonactively sleeping. And at the same time too, we sometimes don't know what our kind of best sleep need is 'cause we're not providing that opportunity. So I think teasing that apart's essential when you're working with clients and general and athletes is trying to understand, okay, they're reporting to me six and a half hours. Does that reflect just the time period they're spending in bed? Does that reflect the actual sleep they're getting over that window? And are they short-changing the amount of sleep they're actually having? And perhaps we should explore a sleep extension period of time to see how they feel when they get seven and a half if they're able to. And I think so it takes a little bit of exploration to your comment about the use of objective measures, consumer-based wearable technology, nearables as well, or kind of the more clinical grade longitudinal trackers, these accelerometers called "actigraphy." I think they can be very useful for sleep duration estimations. And if you can monitor for, say, seven days tend to be a generally good window of time that are kind of stable representations of people sleep over time, I say that with the caveat that like, I know very well that my seven days at certain parts of the year are always reflective, you know, you get me over Thanksgiving or over college football bull season and that might be a lot different, right? Especially March Maddenist time. So I think we want to be mindful of the context in which we're measuring. I would recommend using those devices, especially the clinical grade actigraphs for upwards of three weeks. Okay. That can be a very useful sample and trying to be mindful of outliers in the data, but also if you can have the athlete track subjectively how they're feeling, how refreshed are you? 'Cause that internal data is often really important, especially when we start thinking about disorders like insomnia and things like that. So I know it's not a perfect answer, right? There's always an art form to this, but I think it's stepping beyond just that single question and trying to explore what actually could be the optimal amount of sleep for the day. this person. Do you have them just as you're tracking their sleep, go about their life in their normal daily kind of routine or do you ask them to experiment a little bit to say can you add two hours of sleep and see how you feel for three consecutive days or something like that? How do you approach that? Yeah, I think within that space, getting some baseline data where there's no modifications going on is critical. And oftentimes people have great insight. So once they start tracking sleep and they start rating levels of refreshment or how refreshed they are on the day or they're monitoring at the same time, you know, as athletes tend to do perhaps to harm in certain situations, but other metrics of health in response to sleep, they can start seeing the picture themselves that, okay, when I actually got closer to seven that night, my HRV metrics were a little bit different. You know, I was able to get through that last rep during resistance training or whatever it may be with less struggle. And then there may be more of a willingness to explore extending that window. I also want to be cautious about ever kind of making a guidance or recommendation of extending a window to aggressively as one of the kind of perpetuating issues when it comes to insomnia characteristics is spending too much time in bed awake. So if you are going to explore kind of extending that window, try and do an in gradual increments like 15 minute segments is probably a really advantageous way to do it. Okay. That makes a lot of sense. Not a lot of the athletes were working with, especially collegiate athletes where conferences have expanded from one half of the country to the other are met with multiple challenges, especially the travel from one time zone to another and then back almost immediately. How do you deal with programming in light of these challenges and moving back and forth between time zones and does napping play a role in trying to make up for any sleep death that they're encountering during this travel? It's a major challenge right now for collegiate athletes out there when it comes to sleep health on so many levels. This conference reliant it's certainly exacerbated a lot of the issues. And there's a beautiful white paper out there in the journal of biological rhythms looking at the negative health effects of time zone change for collegiate athletes in particular and sleep insurcating experts, I think like 40 or 50 them really supporting these comments almost like charge comments in some ways to the NCA for what's unfolded. As far as actual kind of approaching these dynamics, I'm a huge believer in sleep regularity. I mean you want consistency in our sleep timing. It's emerging as one of the best predictors of health outcomes downstream. There's a recent paper out that suggests that it's even a stronger predictor of all cause mortality than sleep duration. There's a lot of reasons for that as far as the quality of sleep we may be getting when we get that circadian system on board. It's really supporting rather than being at odds with our sleep period and many other factors. So I still try and think how can we maintain as minimal variation in that wake time as possible? Anchoring that wake time because we can control that with alarms can still set us up for falling asleep at a similar time at night. So we try and focus on that consistent wake time rather than forcing a bedtime. And inherent limitation with that is if we're going to maintain a wake time, well certain scenarios of travel, competition, those types of things, those timings are going to limit our sleep opportunity window. So that's where supplemental napping can come into play as a way to counterbalance, achieve 24 hour sleep of sufficient duration without potentially harming our sleep at night and kind of mitigating this challenging environment, navigating as best we can, these athletes are going through. There are other elements to the travel that are nuanced when we start thinking about optimizing performance, not really an optimized guy from a word perspective, but enhancing our performance and how much we want to attend to potentially aligning our circadian rhythm with new environments to help support not just sleep in that environment, but also performance in that environment. And the beautiful thing about the circadian system is it is malleable. The degree to which is still kind of uncertain and some may be more constrained than others, especially when we're talking about advanced circadian characteristics, but we really want to be mindful, especially when we're going from west to east travel. That's when it's most kind of deleterious for our sleep health. And the example I like to give is if you're working with an athlete who's got an early competition time on the east coast, and they're coming from the west coast, California to Boston, say for the Boston marathon, and they want to perform their best. Well, that sleep the night before is probably going to be a contributing factor. And if you don't acclimate in any capacity, you're vulnerable to having a circadian misalignment. In the sense that that's a three hour time zone change. If you try and go to sleep at 10 o'clock on the clock time in Boston, that's really about seven o'clock for your biology. So I use that as an example of like we can potentially think about shifting the rhythm with a lot of different zeitgeibers or clock and trainers as we say, like being our principal zeitgeiber. We can also think about traveling early and acclimating to the environment. But all these factors kind of depend on how long we're there. When's the competition timing per se? So I think being very strategic about how we approach travel and prepare in advance, giving athletes instructions to help kind of alleviate cognitive burden, cognitive decision making when they land there and perhaps even enhance psychological comfort. I'm much less anxious if I know that when I land, I know where my uber is going to be. I know this is when I want to have my meal timing. This is when I want to wind down. That can go a long way to improving our sleepability and quality at night. And then make sure that to the best of your ability, the athletes have the tools that they use at home, whether that's noise cancelling headphones, certain pillows that support sleep, CPAP machines, whatever it may be with them when they're on the road. So you did mention napping as you were kind of moving across time zones and the potential benefits of that guidelines I've heard are generally about 20 to 25 minutes. You can consider the addition of caffeine before the nap so that you're helping to kind of activate yourself as you're waking up or kind of increasing the level of arousal are those your recommendations as well or is that out of place? Well, I just want to applaud you, Devon, for diving into the sleep culture and getting educated, right? I'll speak to the use of caffeine to potentially bolster the restored effects in a second. To your point, there's a little bit of nuance when it comes to strategic napping. I don't necessarily like the word strategic always puts a lot of emphasis of supplemental napping, some call it tactical napping. I think that's just an interesting way to go about it, but strategic is a nice word. And I like to think that there's two main characteristics here when we think about it. There's the duration of the naps and there's the timing of the naps. As you pointed out, kind of shorter naps are often commonly recommended and utilized and the range of shorter can vary, you know, often between 20 and 40 minutes, but we're really decodamizing between shorter and longer naps and both can be restorative. So that's that's the good news. There are tradeoffs. So with the longer naps, there is a potential for greater restoration physically, cognitively, psychologically due to the ability to go through a full sleep cycle, potentially and achieve deeper stages of sleep. That sounds kind of enticing. However, with the longer naps, you do run a risk of potentially interfering with their sleepability and quality at night. So if anyone's really experiencing difficulties falling asleep, staying asleep during their main sleep period, we really want to steer away from the longer naps because I can perpetuate those issues over time. There's also this term sleep inertia, which is growing more in common nomenclature, if you will, in sleep disorders, but also generally as well. And it's this natural transient state between sleep and wake that associates with impaired functioning, cognitively, psychologically, and physically. And with most people, it often dissipates within 30 minutes. So that's a nice kind of marker, if you will, to allow 30 minutes to pass between time you've woken up either from a nap or from your main sleep period before engaging in either sort of sport training, competition, and ideally, probably even team meetings too. There's some evidence out there that suggests that you may run a risk for greater severity of sleep inertia upon awakening. And that may be because of some of the deeper stages that you're accessing. So that's the trade-offs there with all of these is how much time do I really have to budget for a nap? Sure. I can still get restorative benefits from the shorter ones and as less likely to negatively impact my sleep at night. And yet, longer naps may have more restoration. So finding that right balance for the person, the athlete is critically important. As far as the napachinos concerned or the use of caffeine prior to a nap, I would say it's theoretically makes a lot of sense based on kind of understanding of absorption rates and digestion and things like that. I think there's limited science on it. I've definitely done it before and I've seen the benefits. I'm not here to make a general recommendation that you should or should not. As I think there's other hazards to it as well. Now we're inviting caffeine kind of later into the day into the equation. Maybe that's not the best strategy too, is that maybe harmful for our sleep quality at night? Sure. So it's certainly interesting and I think there is some utility to it, maybe in case specific scenarios, but you definitely want to be mindful of potential harms from overcaffeinating and also at the same time we all respond differently to caffeine. So it may not even, it may hit you much quicker and then disrupt your actual nap itself. That makes sense. Now, obviously with your athletes, you're working with all this research and you have a team kind of involved in supporting them. A lot of people aren't going to have access to all those resources. Just general primary care doc, not at a division one university. What would you recommend in terms of resources that they may be able to access for their athletes without a lot of funding or a lot of specialty, specialization around them? Describing a very practical scenario and this is, I think, what most physicians face. Generally speaking, it breaks my heart that there's a deficiency of specialists, whether that's in behavioral sleep medicine or those board certified in sleep medicine. So let's name that reality. Just as far as resources are concerned, most providers probably don't even have access to activity to longitudinally monitor sleep. So we want to acknowledge that because that's a specialized tool that often requires training to interpret and scores being mindful of those factors. And I think a good place to start is sleep diaries are readily available online. So there's the consensus sleep diary, which was developed to mitigate issues between standardization of diaries that are used. It's a great sleep diary. It provides you all the tools you need. Being physicians, I think everyone will be competent enough to work through sleep diary and calculate our not so sophisticated sleep variables when it comes to sleep latency, wake after sleep on, sent sleep efficiency. There's available resources online. I think CBTI Web is a really good resource for getting more information. They even provide some training around CBTI for providers that are interested on there. There's a new questionnaire that's emerged recently over the last decade that's gaining momentum. It's validating athletes samples. It's translated to a variety of different languages at this point. And I believe it is freely available. It has been previously. So I still maintain that it's probably freely available. And I think it's on the center for sleep and performance website. It's the athlete's sleep screening questionnaire. It's a great tool. I think can be routinely administered regularly utilized across a calendar year to monitor different symptoms. And there's a great composite index called the sleep difficulty scale, which has established severity thresholds developed through science that it suggests when an athlete may warrant a referral to a more specialized care. So I think that's a wonderful tool. When you're time limited, you want a really comprehensive evaluation in the sense that it asks about sleep disorder breathing and asks about travel disturbances. It gives you some indications or cating characteristics. So trying to anchor there. I think also not being shy about using data that's collected from consumer sleep tracking technology. You know, I'm very much more in the optimistic camp when it comes to eventually these being clinically integrated at this time. It's not the case, but they're moving closer. And when it comes to some of the key variables, such as duration, the timing of our sleep periods, the research is showing in these modern devices that they're often comparable and a time superior to kind of our clinical grade act graphs. Recognizing that and integrating that in your conceptualization is critically important. Now being mindful, of course, of the limitations, they're very vulnerable tonight to night, misestimations, focusing on patterns over time, rather than a single night of data. And when it comes to those sleep continuity variables that were interested with insomnia, this time to fall asleep and wake during the night, they're still very vulnerable to misestimations there as well. So really just focusing on kind of the sleep duration and timing is what's most useful from those devices. There are emerging technologies, more accessible sleep atnea screening tools. I know that the Apple Watch recently gained FDA clearance as a tool that can support not actually diagnose individuals with sleep disorder breathing. It's most sensitive and specific to those with moderate to the fear of sleep apnea. So it may miss some of the minor apnea's and there may be some bias when you start thinking about differences in sex is when it comes to sleep apnea. But I think that speaks to these kind of emerging tools that we shouldn't ignore. We just need to be mindful of kind of the cost benefit analysis here. Absolutely. Well, I thank you for all your time and expertise you shared with us today. Are there any other things that I haven't asked that you think I should have covered or any closing thoughts for the listener? Again, I think you do a phenomenal job hosting this. And ultimately in the end, if I can leave providers with one final take home, it's sleeps critically important. And I think society's really woken up to that. No pun intended. And I think that's also the problem is that the pendulum swung really hard. And that's creating a lot of fear and anxiety over sleep. So really speaking with your athletes about their relationship with sleep, how they're viewing sleep, are they worried about sleep and working on that angle could be critically important as well. Because our goal is to create a space where sleep's prioritized without pressure. And we're not trying to perfect sleep. Well, I thank you again so much for your time and expertise. I think this was phenomenal. I encourage everyone out there to consider sleep programming really being proactive about the way you approach it. And I think you don't have to get it perfect. It's not looking for perfection, but striving for better and being proactive and trying to plan for it. And I think we're all going to find more success. So we thank you for listening. We hope you found this time valuable and that you'll join us again soon for the next edition of the AMS SM sports medcast. The views of the speakers are theirs alone and don't reflect the official policy or position of the AMS SM or the US government. [MUSIC]