Mindfulness and Cognitive Behavioral Strategies for Diabetes and Sleep Problems [transcript]

Written by Christopher Kelly

May 5, 2019


Christopher:    Well, Ashley, thank you so much for inviting me here to San Mateo to talk to you about some of the research that you've been doing over the past five years. Can you believe it's five years since you were last on the podcast? Almost five years. We met at AHS '14 in Berkeley. Do you remember that?

Ashley:     Oh my gosh, I'm feeling quite old. But, yes, it's lovely to see you.

Christopher:    A lot has changed since then. So, in 2014, I think you were a lowly post doc.

Ashley:    It's true.

Christopher:    And now you're the king of the castle.

Ashley:    Oh, no. I'd hardly call myself that. But I am an assistant professor at UCSF these days. Things are definitely different than when I was a post doc.

Christopher:    Can you talk a bit about your primary areas of interest in research?

Ashley:    Yeah. I've diversified somewhat since last we met. I'm spending the majority of my time still on eating behavior research specifically we're looking at how to get people to change their behavior around food and eating, both how they eat, what they eat, when they eat, all that good stuff. I'm also looking a fair amount now at sleep and that's been somewhat of a change in the last three years.

    I was trained in how to do behavioral sleep change at the University of Arizona a long time ago. I did it as a resident. And then now I'm actually doing a fair amount of clinical work in sleep at Osher Center which is where I am at UCSF because sleep is kind of a linchpin to a lot of other behavior things, if you think about it. The populations I have been mostly focusing on are people with binge eating disorder, people with type II diabetes, and people who can't sleep.

Christopher:    Talk to me about food rewards and how you get people to change their behavior. You've been involved in some clinical trials where we've looked -- and I say we like I'm somehow involved -- where you have looked at changing the amount of carbohydrate intake and you've seen some great outcomes with that. But having people stick on that diet is not necessarily trivial, correct?

Ashley:    Yeah. There's a lot of different things that motivate people to change their behavior. And if the same thing motivated everyone I wouldn't have a job. But it just so happens that one of my favorite populations to look at is people with type II diabetes. These people often have to take lots of medications. They have to inject themselves with insulin a lot of the time. Their lives are often revolving around treating their chronic illness.

    And so if these people get onto a new life plan or new eating style or a whole slew of behavior changes that allows them to live their lives more than live their illness, that's pretty motivating. We've been looking at low carbohydrate diets or what I prefer to call carbohydrate restricted diets for the treatment of type II diabetes. Right now, we're actually doing a trial where we're looking at whether adding some behavioral components to the standard carbohydrate restricted diet can help people maintain the change for longer.

    Right now, for example in our study, people with type II diabetes, we're recruiting them, and half of them receive just the carbohydrate restricted diet information. They go to those classes that we have. And then the other half gets those classes but they also get training in mindful eating techniques and ways to manage cravings. And so what we're particularly interested in is are the people who get that extra mindful eating training able to adhere to the diet longer in follow-ups?

Christopher:    I want you to go into more detail about what that mindful eating looks like but before we get there, can you explain--

Ashley:    We can go back to the food reward piece.

Christopher:    And the food reward piece, right. Up in that thought. But what I really wanted you to talk about is how do you think these people are getting into this predicament in the first place? How do I get to the point where I'm insulin dependent diabetic? What happened?

Ashley:    Yeah. There's a lot of roads to becoming an insulin dependent diabetic. To say that everyone takes the same road would be mischaracterizing the illness altogether. We know that type I diabetes is very different than type II diabetes, for example.

Christopher:    Of course. Right.

Ashley:    And people with type II diabetes, luckily more so than people with type I diabetes, have the ability to change their illness with their behavior or their diet. They may be able to get off of insulin altogether. A lot of people get into that predicament by consuming too much, period, generally consuming a lot of sugar. Sugar is a very quick way to dysregulate what's going on in your body especially when you drink it in the form of liquid sugar, soda, sweet drinks, which are every way you turn. There's probably -- I'm trying to remember the most recent statistics but it's more than two-thirds of Americans now or something like this have dysregulated blood sugar in the clinical range, prediabetic, diabetic.

Christopher:    Yeah. I mean, it's terrible. We've talked about some studies on the podcast before and I can cite one where they did -- It was quite a large study. I think it was in the thousands. And they created some objective measures like your triglycerides need to be below this and your waistline needs to be below that. And they found 12% of the study participants were deemed to be metabolically healthy. Meaning, 88% are now metabolically deranged.


Ashley:    Well, you asked for a specific question which is how do we get ourselves into this predicament and you just go outside and walk around and look at what food is available and how easily it's available and the prices at which it's available, I think you'll have your answer.

Christopher:    Right.

Ashley:    Cheap food that is not good for you is very easy to find. Cooking at home seems to be a lost art. Buying actual whole vegetables, unprocessed meats, and cooking a meal at home takes a significant amount of time. And Americans spend way less time cooking today than they did decades ago.

Christopher:    Wow. Yeah. We've just been experiencing this personally in San Francisco. I was there for a conference and we had an Airbnb. I thought the Airbnb would be better because there was a kitchen. You can't cook yourself when you're in a hotel. We're going to the kitchen, and I say we, I mean Julie, my wife. She's like opening drawers in the kitchen and there's no pan. There's candy in every single drawer in the kitchen. Eventually, we found one pan, one sad pan and that was it, and the perfectly spotless gas range that's never been used.

Ashley:    Never been used.

Christopher:    Never been used. What do you do? And you forget that in San Francisco you've got Grubhub and DoorDash. You can get anything you want from any amazing restaurant in San Francisco. You don't even need to leave the house anymore. You can just use your cell phone. It's incredible.

Ashley:    It's too true. And these foods, not only are they foods that we're not cooking so we don't have control of what's in them or how they're made but they tend to be maybe a little bit too tasty. One of the questions you asked about food reward has to do with this. When we become acclimated to eating a certain level of tastiness of food, other foods isn't as appealing.

    I like to call this the vacation effect. People go on vacation and they eat decadently. They'll go and they'll eat all these fancy foods especially in cruise ships and then they come home and all of a sudden their normal day to day lunch just seems so not worth eating anymore. It's this kind of hedonic treadmill a little bit where we get used to eating some super tasty food and then going back to maybe simpler food isn't as rewarding anymore. We're changing our set point of reward.

    It's kind of like my favorite example. I think I even said this on your podcast four or five years ago. We're not biologically wired for the neural experience of a Twinkie. Nowhere in nature do you find that combination of fat, refined sugar in the absence of fiber. It doesn't happen. You're finding a honeybee's nest, it's just straight up honey with no fat, or you're finding a bison which is fat and protein with no sugar. You're not finding Twinkies. That's kind of a super stimulus. It's just too good.

    And when we get used to too good then all of a sudden the simple things like fresh strawberries on a June Saturday aren't as rewarding as a strawberry milkshake from In-N-Out. Do they even make strawberry there? They might just make chocolate but I don't know. But my point stands. We get used to these hyperpalatable foods and we eat them. They trick us. They kind of hijack our brains and we no longer are focused on feeling sated or feelings of satiety. We're focused on those feelings of reward, "Oh, this is tasty. I want more and more."

Christopher:    We're not the only primates that are affected by this either. We just got back from Costa Rica and we went into this national park that had a jungle and you're expecting to see lots of monkeys because that's kind of why people are there. "Where are all the monkeys?" And then you get to the beach, which is on the far side of the jungle, and that's where all the tourists eventually end up. Everybody sits down in the beach.

    Of course, when they sit down, they get their food out and that's where the monkeys are. The white faced capuchin monkeys, they come down the tree and they're just stealing food and it's amazing to watch them. Like why would I mess around with all these fruits in the jungle when I can get Doritos off of this man while he's putting suntan cream on? It's fantastic.

Ashley:    There you have it. I think that gets a lot of people into predicaments with their health. Actually, I have a post doc right now and she's doing some work with stress eating and behavior change and something that comes up sometimes is people say, "I just don't like the way vegetables taste. They don't taste good so I juice them instead. I don't eat them." Figuring out how is it that people can cook things that do taste good that aren't good for them. Maybe that's, I don't know, frozen pizza or frying something, frying bacon. They can do that. But at the same time they've not figured out how to make vegetables taste good. By the way, that was not a hit on bacon. I know that's a very contentious issue.

    But my point stands, which is that we don't have a culture of learning how to cook simple foods in simple ways that taste good because we go to these restaurants and we go out to eat where they have these commercial kitchens and these chemicals and these ways of cooking that we can't necessarily do at home or replicate. And we get used to how good that tastes.


Christopher:    How do you go about getting people to change their behavior when they're part of one of your trials? I mean, it's not trivial, right?

Ashley:    No. When you think about people with type II diabetes, who we put on these carbohydrate restricted diets, all of a sudden their morning blood glucose levels are lower, their ketone values are higher. We give them ketone meters and other Precision Xtra type stuff. And they get this reinforcement, "Oh, I'm doing a good job." So, that's nice.

    But then also, in our trials, we have an endocrinologist in the trial and people are just taken off of drugs. In our trials, people, they quit and quit and quit their drugs. Probably like you saw on the Virta paper. Massive quitting of drugs. And when you don't have to inject yourself so many times during the day, it's pretty reinforcing. When you don't have to take drugs that have cramping side effects in your calves every day anymore, that's pretty reinforcing.

    People who don't have type II diabetes might not have the opportunity to have those specific types of reinforcers but those are pretty motivating for a lot of people. "I really enjoy not taking insulin pens everywhere. I really enjoy not having to take Glipizide every day." Those things can motivate to maintain behavior change for a lot of people.

    It's hard to describe to you what the face of a person who just had a blood test, an A1C value that's in the normal range, the expression on their face when they haven't had that for years, decades maybe. So, we can say, "No, your blood sugars do not look as though you have diabetes right now." That's incredibly motivating. For that population, those motivators are going to be very different than for someone who doesn't have type II diabetes.

Christopher:    Right. What do you do with someone that doesn't have type II diabetes? Maybe I don't have something that's poking me in the eye quite so sharply.

Ashley:    Right. Well, then, why do you want to change? What's going on?

Christopher:    Yeah. How do you get to discovering that?

Ashley:    Well, you have to ask people.

Christopher:    And do they tell you just when you ask them why do you want to do this and they're just going to give you the right answer right away or is it a bit more complicated than that?

Ashley:    People like to give you all sorts of answers and you have to get to the bottom of what's really going on.

Christopher:    Okay.

Ashley:    So, for example, someone will say, "Oh, I've got a wedding coming up in two months. I really want to look great in that black dress." "Why? You're going to see someone there? Pictures? Who's going to see those pictures?" Like what's going on? Why does that person really feel like they needed to change how they look for an event that's happening essentially in one night in two months?

    So, figuring out, okay, maybe that's not really what's going on. Maybe that's not the real reason. Figuring out what it actually is can really help people actually then go about making change. When we clearly see the rewards of our own behavior then it's much easier to change. When you think about those two bags of potato chips that you -- I'm using the plural you -- eat when you get home from work sitting on the couch at night while you're watching TV, if we really think, okay, what's the real reward of eating those potato chips? What are they really doing for you?

    In that moment, okay, they're reducing your stress? Are they really? Okay. What are they doing for you the next day? A good example is a hot coal. Let's say you're really, really cold outside. It's snowing. You're freezing. Someone gives you some hot coal. And at first, you're like, "Oh, this is warm. This is great." But then you realize, "But it's burning through my hands. This is not great." Then you drop the hot coal. Once you're able to clearly see, "Oh, this is not helping me get warmer. This is actually burning me." You're able to let go of it.

    Once you see clearly the effects of the behavior you're doing whether it's eating chips at night on the couch or going to town on the third pint of ice cream on a Tuesday afternoon in the office, once you really see what are the rewards of some of your behavior, it's much easier to change them. But first, understanding where's the desire for change coming from and then also understanding clearly what are the real rewards of doing the behavior. Then it's much easier to start unpacking them and to change.

    For a lot of people, simply awareness is going to -- You can't un-know that Santa Claus isn't real. Once you know -- Oh, I'm doing the thing again. It's hard to un-know that you're doing it. And, I guess, this is a question I feel like I get a lot and my answer is always, "Well, it's going to depend and it's going to be different for different people." I know on previous podcast, I think, people have touched on motivation interviewing, eliciting change talk and figuring out where people in the grand scheme of readiness for change. I always joke that I've been in the pre-contemplative state of getting a fish for about ten years, which is why there's no fish in my apartment.

Christopher:    Right. Hang on a bit. You said, that means you've contemplated, isn't it?

Ashley:    Pre-contemplative. I've been thinking about thinking about it for about ten years. And that's where we're at. So, figuring out where people are in terms of their readiness for change and figuring out what's really driving the desire for change is really key because I don't know about you but most people tell me, "Oh, I'm trying to lose ten pounds for a wedding in two months," most of the time I don't think people get where they want to go.

Christopher:    Right. Say, you are working with a patient, you would then say, "Okay, I don't think this is a very good reason to do this."


Ashley:    Oh, no. I wouldn't judge their reason but I would probably ask them more about their reason.

Christopher:    Right. And what, would that normally lead to the real why and then perhaps that real why is going to be a more persistent value than the wedding.

Ashley:    "Why do you want to lose the weight before this wedding?" "I want to really look good at this wedding because my ex is going to be there." "Are you hoping to get back together with your ex? What are your thoughts on your ex?" "Oh, no, I just want him to see me looking great." "Oh, what's that going to do for you the day after the wedding? How's that going to change?"

    I mean, at the end of the day, you often get down to themes of I'm not good enough, I'm not enough but people think of me, dictates how I think of myself. You get down to a lot of that stuff. And once you start unpacking that then you can actually see what really needs to happen.

Christopher:    So, presumably, when that's true, then the food, the eating is just one manifestation of that problem and probably that person is making other decisions that they don't--

Ashley:    Sure. It's much easier to bury yourself in a pint of chocolate ice cream than to really think about the problems that are happening. Since really thinking about the problems that are happening isn't really fun at 7:30 p.m. on a weekday after work, maybe if we can just clearly see the rewards of what that pint of ice cream is doing and then it's easier to just let go of it rather than have someone pry it from our hands. That's maybe a little bit of a better route to go.

Christopher:    How do you have people handle the social pressure of eating differently? That's something that I hear come up a lot as well. You're the virtuous guy that's going to eat the salad when everybody else is having some sort of refined carbohydrate and refined fat combination.

Ashley:    I'm a little bit of an outlier in this way because I really just don't give a hoot or a holler what people think. And generally when I'm going somewhere and I know that there's going to be nothing that I want to order for dessert, I'll bring some fancy dark chocolate bars and I'll just share them with everybody at the table. I'm going to say, "Oh, look, I brought these." It's never really a thing.

Christopher:    Everyone spits them out.

Ashley:    Or people look at them and they say, "But I really want this cake." And I say, "All right, you do you. You get the cake. I'm going to have my chocolate bar."

Christopher:    That works for you but would it work for patients?

Ashley:    My patients mostly have type II diabetes so when they say, "No, I can't have that because I'm working on managing my diabetes," that works. Most people don't give them ish about that.

Christopher:    Right. And that could work for other, say, "Oh, I don't want to eat that because I've been having some gut issues recently and I'm just trying to keep it simple at the moment."

Ashley:    I also don't always think that people even need to give a reason. Just say, "No, I'm not having that." And if people come at you and they want to talk about it, fine, but it turns out most people don't really care. So, if you just say, "No, I'm going to have a salad," you don't need to qualify that. This bizarre expectation that if we're going to make a choice that's good for us, we have to really say a good reason. It's just bizarre. Shouldn't people be justifying ordering the pizza?

Christopher:    You're right. They should. But you are usually in the minority.

Ashley:    Probably. But it also depends on -- So, with participants, for example, we have a lot of folks come in and we say, "What's a classic for your family that you bring to a potluck?" Some say, "Oh, I always bring mashed potatoes with da-da-da." We figure out, okay, what's an alternative way to make it that's going to make it work with this? We try the cauliflower thing or the [0:18:14] [Indiscernible], whatever the things are that we try with them. And they try making different ways and they say, "Oh, this is actually good."

    And then they might bring it to their families. "This is better for my diabetes than the other one that I used to bring. It's probably better for you too." So, we can re-conceptualize those sorts of things as, "Well, I really care about my health and you're my family. I really care about your health so I'm bringing a healthier thing to the family event this time."

    And they can also make it about kids. Whenever there's kids around, you can say, "I really want the kids to learn how to eat these healthy food or eat this extra vegetables." And who's going to argue with teaching kids eat vegetables? Probably not very many people. It also happens to be the case that when you go out to eat you can look at menus online ahead of time these days. There's lots of ways to do that. You can even pick restaurants based on what food there might be available.

    I think that in a lot of ways, giving reasons for your choices only makes you seem a little bit more attackable. When you're out, just say, "No, I'm just going to get this."

Christopher:    Do you think I'm right in thinking that though, that humans generally do have a desire to explain their behavior?

Ashley:    They often do. What my challenge is to say I think people don't need to do that so much. And once they try not doing it, it turns out it's not that hard. And if someone asks you about it, you could actually share with them in a non-pedantic way, "Oh, I've been eating less carbohydrates lately and my blood sugar is lower. I don't have to inject as much insulin this way so I like it." I don't really think anyone is going to pick a bone with you about that.

    And if you're out and you say, "Oh, I've been eating less carbs because then I get less late night munchies and I don't like to eat too late at night," I don't really think people are going to argue with that either. If you're really around a lot of people who are trying to sabotage your health, are those the people you really want to be around anyway? I think it invites a lot of opportunity to think about who you're with.

Christopher:    I'm just thinking about the work environment, especially.

Ashley:    Sure.


Christopher:    I just remember -- I mean, I shouldn't say anything because I could identify people. But I've seen that work environment where you're basically torturing somebody with type II diabetes by surrounding them with food choices from Costco in a stationary cupboard that they absolutely cannot eat. And it's really hard to regulate your behavior when you're constantly reminded with the stuff that's super tasty.

Ashley:    Yeah. I mean, even if you look back -- I mean, so, we're standing in my apartment. If you look back toward my kitchen and you wondered where are some of the tastiest things, where do you think I'm hiding them?

Christopher:    Nice cupboard.

Ashley:    They're hiding in those cast iron closed pots so you can't see them. If they were in glass jars out front in the counter I'd be thinking about them all the time. But out of sight out of mind really does work.

Christopher:    You just made me realize that my Airbnb host is perhaps smarter than I originally thought. That's why all the--

Ashley:    Hiding all the candy.

Christopher:    Hiding all the candy, yes, so you can try and throttle back just a little bit.

Ashley:    One of the things I also recommend to people is bring your own snacks. If you're in an office full of Costco treats, ask, "Who's ordering all the Costco treats? Can I put in a preference for something?" Or bring your own. That's what I've always told my husband who's worked at startups and tech companies. "What are the snacks?" And he sends me a picture. And I say, "Who's ordering the snacks?" And then he finds out who it is and he puts in his own request.

Christopher:    That's great.

Ashley:    Yeah. It's just a little bit of extra effort and then a little bit of just really thinking clearly about situation. I'm out of dinner. They're pressuring me to order pizza. What's really going on here? Put it on the table. What's really going on? Why do you need me to order the pizza? Feel better about yourself?

Christopher:    What do you do about the pre-contemplative? So, I've just been at a conference in San Francisco and we just said only 12% of Americans or westerners are in metabolically good health and I'm sure these data scientists I was hanging out with were no different. They brought out breakfast, lunch and dinner I didn't see but it was essentially refined carbohydrates. It was like a children's birthday party. That was how I best describe it.

    These data scientists, they're competing to solve this problem with machine learning and they're all in the same room, sat around these round tables and these little pots of little tiny cups with M&M'S. It's basically a continuous drip of glucose. Like keyboard here, just to the right, we got my little pot. I mean, those guys, I would never say anything about what we do at NBT or I talk about on the podcast. I would never even think of talking to them about this stuff because they don't even know.

    It's like what you said about Santa Claus. They still think that Santa Claus is real. And then they don't even know they have a problem. What do you do about the people that don't even know they have a problem? Do you have to wait until they're an insulin injecting type II diabetic before they can even consider changing their behavior?

Ashley:    Well, yeah. I don't think we're in a nanny state. I don't think we're in the era of everyone telling each other what to do. I see patients when they come to me and they say, "I have a problem." I'll say, "What brings you here today?" If someone doesn't see something is a problem then they're not going to be in my office. How am I going to reach them? I don't.

    When people come and they present with whatever problem it is that they have then we can work with that. if someone doesn't think they have a problem, it's not really our problem. But at the greater society level, the fact that we’ve got government programs promoting when it comes to if our friends are just doing things that aren't good for them, do we have an obligation to foist their opinion on them about what they should be doing? Not so much. Generally, it's not very well received.

    But in terms of the example that you just gave me, I don't really know how those people end up in the offices of people who do behavior change services or how they end up at their doctor's offices. Those are all their choices. I'm really not sure what we can do about that. But in terms of situations where we as a society are providing for people in need, we definitely have a lot of progress to make.

Christopher:    Five years ago, when I interviewed you for the first time, I thought, "Are they going to figure this out? The nutritional guidelines will change and that will be the end of it." But, of course -- Actually, I'm not even sure that these guys even pay attention to the nutritional guidelines. They pay attention to what they have right in front of them.

Ashley:    Their checkbooks, right. Everything's all mixed up because there're different lobbyists that pay for different political people to do different political things that end up with different taxes and different prices. It's all kind of all tied together and rigged so it's very difficult to see how we're going to actually get healthful food to people who need it.

Christopher:    So, it's not going to happen from the top down, right? Because the nutritional guidelines haven't really changed and those lobby groups know the rest of it. And it's probably not going to happen from the bottom up either because generally people don't take kindly to being told what to eat by their friends, the virtuous friends that have just--

Ashley:    But it's interesting, I've gone to lunch at a few different tech companies with friends who either have left academia or who never entered it in the first place. They just said, "No, not going." And you look at the different prices in the lunch room for different things. Now, a lot of them are free but I'm thinking of a couple of them in particular that aren't.


    The healthy food is actually much cheaper than the unhealthy food. Now, the company is probably losing money on that. But what are the employees buying more of? The cheaper food. We know that money drives a lot of decision making. Taste also drives a lot of decision making. But if we actually have the ability to make some changes to how food is priced and that's done through various channels that I think could be independent of nutritional guidelines, we can make some of those changes. I think we can nudge people toward making better choices.


    And I don't think we need nutritional guidelines to say, okay, apples should have a larger subsidy than apple flavored juice. I don't think we need a large consensus about should everyone be a vegetarian or not type proclamation to make some of those changes. And I think that a lot of those companies that are doing really well could do a better job by their employees by making healthy choices more accessible.

    It's tempting to name names but I shouldn't. One of the largest tech companies that you can think of that I was recently visiting at, they've actually done some really interesting stuff with how they arrange their little micro kitchens, is what they're called. All of the sugar beverages are behind washed glass. All of the waters, clearly visible. The fruit is on the table. All of the processed candy bars and energy bars and packaged goods are in opaque drawers. So, it's easier to make the healthier choice.

    And we know from a lot of research in cafeterias in schools that if you make the apples easier to reach, students will take more of them relative to making strawberry flavored milk at the front of things. It's easy to nudge people to make better choices. I don't think that's very "nanny state" like. It's not we're taking away options.

Christopher:    Right. You're just changing the default.

Ashley:    Just changing the default. And was there ever really any good science for what the default was? No. That was just based on economics.

Christopher:    I ride bikes with a friend and his girlfriend does marketing inside one of these big tech companies inside of Silicon Valley, the food department. I thought that was going to be all about what you just said. It turns out, no. Marketing inside the food department at one of these big tech companies is about bringing in celebrity chefs and sending this message that we have the best food in Silicon Valley. And so all the employees are really doing is trying to optimize for their employee's happiness. We know exactly how to do that.

Ashley:    Yeah. I think they're optimizing but I also think that now they've most to some of these self-insured type health plans since the way that those health plans work, if I understand them correctly, is that there's a big pool. There's a big pot of money there. They actually benefit from having healthier employees.

Christopher:    I see. So, the employee might not be aware of this but that's how your insurance now works. Your employer is actually self-insured.

Ashley:    If I understand correctly, I think that a lot of these big health plans with these big companies, that it can work that way.

Christopher:    Okay.

Ashley:    Having been insured through my husband's insurance when he worked at Apple a while ago, whenever I would call he would say, "Welcome to United Healthcare for Apple." I had my own line. It was kind of weird. So, I'm thinking, okay. And when you went there you really did see all the labels and all the food, the calories and the ingredients. So, you were making informed decisions now whether those things actually work in the wild. Adding calories to menus is up for debate. I know that's a hotly contested are. I'm not going to touch that one but I do think knowledge is power. So, looking at those lists, I'm thinking, okay, the first five ingredients on this list are all different type of sugar. Maybe I'm not going to have that.

Christopher:    Talk about mindful eating. What does it mean?

Ashley:    Yeah. So, a lot of folks have been interested in mindfulness in general and the overall trials looking at mindfulness interventions for obesity and weight loss haven't been terribly impressive. That might be because those aren't really going at the target behavior, which is specifically eating. So, right now, we're looking at mindful eating as a way to help people adhere to dietary change.

    In a nutshell, it's paying attention while you're eating to everything. The food that you're eating, how you're feeling while you're eating it, how you feel after you eat it. Mindful eating is not eating while you're in your car on the way to work, eating while you're watching TV, multitasking eating, mindless eating. It's the opposite of all those things.

    What we know about paying attention is that it can really help people figure out what they actually do like and what they don't like. My favorite example is actually cigarette smoking which is a little bit more of a blurred contrast. But back when I was at the VA and I was working in a smoking cessation clinic, there were a lot of folks who went through treatment and it didn't work.

    They tried the regular quit programs and they just didn't work. And I remember I had a patient who was referred to me and he always told me, "I hope you're going to tell everybody about me and what I did." And I said, "I'll use your story. I'll never say your name but I'll tell your story." He loved smoking. Loved it. Two and a half packs a day. And he came to me and said, "Look, I love smoking. This is what I do. I'm not quitting."


    I said, "That's awesome. You love smoking. So, tell me all about your smoking." And he was like, "Oh, this is odd. You want to hear why I love smoking?" "Yes, absolutely. I need to know. Absolutely. Because I've never smoked. I didn't know anything about it. Please tell me what you love." And so he told me all about his different smoking. I mean, where he smoked, how he smoked, when he smoked, who he smoked with, what he was doing, all things.

    And I said, at the end of the first session, I said, "it sounds like smoking is really important and you should definitely keep doing that." He gave me this cross-eyed look. "Who is this, psychologist? My gosh." And I said, "But you know, it seems so important that I think we have to turn off the TV while you do it and we really shouldn't have the newspaper out and we really should drink coffee separately because this is really important. We need to smoke. Sitting, smoking and paying attention to it."

    Now, a lot of people, when they just smoke like that, they said, "It doesn't taste so good, actually. I don't really like this. This isn't so good." And other people, they say, "Okay. I'll do that." And they still love it. Now, this patient, did he do it and still love it? Yes. But did he go from two packs a day or two and a half packs a day, even, to five cigarettes a day? Yeah. It was a ritual. He mindfully smoked them.

    A lot of people say, "I failed as a psychologist. I didn't get him to behavioral medicine. I did not get him to quit smoking." I say, "Yeah, I failed. But he sure got some of the peripheral neuropathy got a little bit better for him." Because it was less smoking. So, what I tell people is, "Oh, you love that chocolate cake. By god, we have to sit at that table and eat chocolate cake." Smoking was so important so we had to just smoke, nothing else. Just like eating chocolate cake. If it's that important, we do it with nothing else.

    So, divorcing the eating behavior from whatever, or just the eating from the behavior that goes with it, is a huge first step. And there's another example. I mean, there's little ways you could think of how to pack your own behavior but I had one patient who also, a smoker, we just changed the time of her smoke break. We just changed the time.

    She would get so annoyed she was out on her smoke break that she wanted to go back in to the office where everybody was doing something or she was missing something so she'd put out the cigarette early. But then comes smoke break time she didn't really have the craving because she had already smoked a little bit during her not smoke break. It turns out that separating, just breaking up the routine of the thing is enough to disjoint or dislodge whatever the thing is that we want to change. In her case, smoking. In someone else's case, it might be chocolate cake. So, I would challenge people to think about what all are the circumstances surrounding their eating and can we change some of those? And then look at the eating.

Christopher:    As a former smoker, that does resonate with me, actually. I remember when I gave up smoking I wondered what I would do with my hands whilst I was drinking on a Friday night in the pub. It was like a real concern for a while. But, yeah, like anything, you get over it. My question is, though, how do you insert this mindfulness? By definition, you're not being mindful. How do you inject this intervention into somebody's life if they're not paying attention?

Ashley:    The first thing is teaching people how to pay attention. We'll have people do various mindful eating exercises in the lab sometimes. We'll give them the classic -- Example is a raisin. You tell them, "Inspect this as if you were an alien and you'd never seen this before. Smell it. Squish it." All those things. "Eat it very slowly. What are those flavors?" And we try and tell people, "Okay, now you know what it is to actually eat mindfully. Practice this for five minutes at one meal a day or something."

    How do we get people to do that? Well, okay, do you have a smartphone? Great. Do you like timers? Great. Let's set a timer for when you start eating dinner to remind you to try doing this. There's a lot of different techniques that people adopt to try and slow themselves down while they're eating so that they can do the mindful eating, putting their fork down between every bite, for example, is a classic one, making sure that we've got a checklist of the eating environment down. The TV is off, this is off, all these distractions are put away.

    Shaping your environment is huge. People have to be motivated to do that. The reasons for change have to be very well understood by the person who's doing this change. Otherwise, nothing else will follow.

Christopher:    Yeah. I can relate to that too, actually, with the eating. Lunch time is a difficult one for me. I think it probably is for a lot of people too. You're on the go and the temptation is to keep doing 17 other things as you're eating lunch. And for a while I went through a period where I thought I was eating something that was causing some sort of sensitivity and it would send me running to the bathroom. But what it really was I was just like gulping down--

Ashley:    Too fast.

Christopher:    Yeah, too fast. You're just not in a parasympathetic state ready to ingest food. You're still in the middle of running from a wolf or something. Generally, people don't digest stuff well when they're in that state.

Ashley:    No. Sure. I mean, this isn't to say that I'm some sort of pillar of perfect mindful eating. I'm certainly guilty of eating while at my desk and all of the other things. But when it comes to looking at behaviors that are perpetually causing a problem and wanting to make those changes, starting with practicing mindful eating at a certain number of your meals per week or one meal a day or one snack a day is a great place.


Christopher:    And do you think this is a general recommendation for anyone listening? All the people listening to this podcast are already going to be like the health maximizers. They're already doing a lot of stuff. Do you think this is a good general recommendation for people that don't really have a problem?

Ashley:    I think, in a lot of ways, it is because a lot of people have kids at home and teaching them what it means to sit down to a meal at a table and not have the TV on at the same time and say, "Okay, we're eating now. This is what eating is. Are you full? Is your food tasty? What do you like on your plate?"

    Teaching them that eating is separate from all of the other things that they're doing is a great things to do. So, in a lot of ways, yes, I do think that this applies to everyone. But I also think that the flipside applies. This is where a lot of the mindfulness folks and I might disagree a little bit which is that I do think that the environment is really important.

    I do think that certain aspects of mindfulness and being mindful are effortful. Some of the people at the top of the mindfulness world would say, "No. Being mindful is effortless. It's just attention." Yeah, it's attention. But at the same time, we're tired at the end of the day. Our resources are often depleted. It's much easier to vow to stick to a diet at 7:00 a.m. than at 7:00 p.m., right?

Christopher:    Right.

Ashley:    I think it's important to think about your environment. You have the cereal boxes and the M&M's in a clear glass cabinet where you can see them all the time. Can you switch those with the glasses? Can you make your environment a little bit more opaque when it comes to seeing those unhealthy foods? And people are like, "Ugh, that's not going to work. I'm going to know it's there." But I'm telling you right now--

Christopher:    It's different, yeah.

Ashley:    I love chocolate bars and if I have them in that cabinet in the kitchen I eat them way faster than if they're over there in the dining room hiding in a pot. I might even forget about one of them. I hide them all over the place and I just -- I remember when I really want one and I know it's going to be there but there's no passive wanting. That's not draining on me. I think that there is a happy medium between manipulating your environment.

    There's no Twinkie's at 2:00 a.m. in your house. You can't eat them. And also being aware. Okay, I really like this food and the first few bites were really good and I'm actually full now. It still tastes good but not as good as the first bite so I'll save the rest and tomorrow it will taste just as good again the first bite. Just applying some of that. I don't really see anybody who that wouldn't help.

Christopher:    Yes, only for me the problem was being on my own at lunch time. We breakfast together as a family with no TV at the table and everybody's paying attention, all that. And then dinner would be the same. It was when I was left with my own devices for lunch, that's when the problems would start because there wouldn't be that same environment and I would, yeah, just eat stuff on the go. That's really helpful. Thank you. Talk about how you became re-interested, shall we say, in sleep.

Ashley:    When you don't sleep well, what goes well?

Christopher:    Pretty much nothing.

Ashley:    Turns out, right? As people would always be saying, diet, exercise, diet, exercise, I would think, well, it's hard to exercise when you're tired. It's really hard to follow through on your diet choices when you're tired because who wants to cook eggs when you can just pour a bowl of cereal? When you think about it, sleep is a linchpin to health behavior in general.

    When we don't sleep as much, we also know that our blood sugars are higher. If you deprive someone of sleep, you can actually start to see their sugars drift into the prediabetic range in just a number of -- I think it was days, like seven days or something. And it turns out, intervening on sleep is not that hard. I do cognitive behavioral therapy for insomnia in a group at the Osher's Center. I have rotating groups around five or six groups a year. I also see some individuals. So, it's about 20% of my time I spend doing clinical sleep work.

    It is my favorite because I can see people's lives completely change in five weeks just by changing some of their sleep behavior. I've watched people get their driver's licenses back, go back to work, all sorts of major, major life changes happen after they fix their sleep. And it's really hard to fix anything when you're not sleeping well. There's also a lot of stigma around sleep problems.

    If you go into work one day and you tell your boss, "Hey, I'm really sorry. I need to get to the doctor because I'm having a knee replacement surgery next week and they have to do a pre-op procedure," your boss will say, "Of course, you do. Of course, you got to go." But you call your boss and you say, "Hey, I really didn't sleep last night. I'm not thinking clearly and I think I need to drive home before I might get a car accident later or something." Your boss is going to look at you like, "What? You didn't sleep well just like the rest of us? Go take a cab."

    There's a lot of stigma still around not sleeping well as if it's someone's fault. They're doing this to themselves. We see this in obesity too a lot. There's a lot of stigma there. When it comes to intervening on sleep, we know that cognitive behavioral therapy for insomnia works. There's steps. You follow them. You get better. And that's why it's one of my favorite things to treat.


    You also see so many things in people's lives get better when they start sleeping better. Their social lives often improve because they return going to social events. Like I said before, they had their driver's license back, they go back to work. All sorts of other good things can follow. And so it's kind of a platform for making other behavior change possible.

Christopher:    I know you can't name names but can you talk about a patient who has had their life change? Can you talk about the type of sleep challenges they were facing? Was it getting to sleep, staying asleep?

Ashley:    Oh, my goodness. One of the jokes that I have with my lab is that we're in the business of getting people off of drugs. In our diabetes trials, we get people off of their diabetes drugs. And in my sleep clinical work, I get them, try to get them off of their Ambiens and the things ending in pam, Diazepam, Lorazepam, all the pams of the world, the benzodiazepines of the world that are not -- They shouldn't be sustainably used to induce sleep. We know that these drugs are messing with our sleep architecture. They're changing how we cycle in and out of deep sleep to light sleep and so on. Let's see. I've had patients ranging in age from 20 to, I think, 80 in my sleep groups.

Christopher:    Wow, everyone.

Ashley:    Everyone. And, gosh, I've had so many patients. I remember having one in particular who actually she was living in a group home for older people and routinely was waking up way late in the afternoon and by the end of treatment was actually waking up much closer to 10:00 a.m. and able to go to lunch with her friends and go to the afternoon activities. This was just so exciting for her because it increased her social interaction in her life by 50% because meals are when they saw people.

    And she was also another example of patient who said, "Please tell everybody they can do this because then they can go to lunch with their friends. Tell them I did it so tell them they can do it too." That's one example. I've had patients who've been on hefty, hefty doses of Ambien who were reactively using sleep medications in the middle of the night. They'd wake up in the middle of the night, go back to sleep, they take some drugs, they go back to sleep. Get them off of those drugs.

    I have had people who had given up their driver's licenses. I had one person who gave up their driver's license and was still going to work and was taking lifts every day to and from work because they were just afraid they were going to kill someone.

Christopher:    Because they are just so tired all the time.

Ashley:    They are so tired they were afraid they were going to kill someone. But they knew they had to show up at work.

Christopher:    I bet they're doing a great job.

Ashley:    Well, I mean, I bet they were once they got there because they were hyping up on stimulants but smart enough to know they shouldn't be driving. I've had people on all sorts of professions who've come in for sleep but one of the major things about it is my boss doesn't know I'm here, this is a really big problem, I'm scared someone is going to find out, and I need to fix this so that I can do all the things I'm supposed to be doing, being a parent at home, being an attorney at work who bills every six minutes.

    There's a surprisingly large number of attorneys who seek help for sleep problems, actually. It's pretty remarkable. There's all sorts. Gosh, everybody. There's so many things. I've had artists who've come in and say, "I don't get creative until one in the morning and I really want to try and figure out how to do that during the day that I can sleep at night." And that requires a bunch of other changes that we do. But the key thing is that everybody has the same goal and sleeping is very motivating. It's another example of one that's pretty easy to get people to adhere to some of the extreme changes that I made them do.

Christopher:    We talked a lot on the podcast before about chronotypes and the importance of food timing in circadian rhythm and we talked about light exposure. Perhaps I'll link to those episodes in the show notes so that I'll save you some time here. But perhaps a better use of your time would be if you just sort of generalize, can you walk us though these steps? You said there's some steps.

Ashley:    There's ten steps.

Christopher:    With the CBT. How does it work?

Ashley:    Yeah. So, it will be hard to sum up all of the treatment in a short few minutes for you.

Christopher:    That's what I thought. I'd save you the job of--

Ashley:    But what I can tell you is that one of the major things that we do is we have people get up at the same time every day. Every day means seven days a week. When you wake up at 5:00 a.m. on the weekdays and 10:00 a.m. on the weekends, you are giving yourself some serious jetlag. There's only a three-hour time difference between San Francisco and New York but if you're waking up that amount of time different on weekdays and weekends, you might as well be flying to New York and back. So, working on set wake times is really, really key.

Christopher:    And you think that's common then? You see that in a lot of patients?

Ashley:    Oh, yeah. People who come in who can't sleep, they're sleeping whenever they can. A key thing to know about sleep problems is that what starts the sleep problem and what perpetuates the sleep problem are generally very different things. The example I'd like to give was one I was treating a patient who'd been in a car accident making a left hand turn and was sick of making right hand turns all over town because that was what the patient then was doing to avoid left hand turns for months after the accident. It's exhausting.

    What caused the problem was she got in a car accident. What perpetuated the problem was that she was making right hand turns all over town and she wasn't getting in an accident. When it comes to insomnia, a lot of people will have a traumatic event, maybe a breakup, a job loss, a family change, a move, something big, and they lose their ability to sleep regularly.


    And they're so tired that they start spending more time reading in bed, having a snack in bed, talking on the phone in bed, doing works with friends on their iPad in bed, doing everything in bed just in case they get tired enough to fall asleep. And before they know it they've moved their life into their bed. So, life happens in the bed. Not sleeping.

    And we're supposed to associate our beds with sleep and sex. That's it. What has started someone's insomnia may no longer be what's perpetuating it. What's perpetuating it is the behavior. In this treatment, we remove all those things from the bed. The bed is for sleeping and sex, not iPad reading, not any of that stuff. We move that to the couch and we make the bed a place where if you're not sleeping in it, you need to get out of it. You need to go to your couch and do something else or go somewhere else and do something else. And that's a major change for a lot of people.

Christopher:    And so would that include if I can't get back to sleep, I've woken up at 200 a.m. I can't get back to sleep, I've been here for 45 minutes now, you've had me get out of bed and--

Ashley:    I wouldn't let you stay for 45 minutes? I don't even let you stay for 20 minutes. When you get out of bed, you do something else for 20 minutes, something that's pleasant, not work, but boring enough that when you're sleepy again you'll go back to bed, not riveting and exciting enough that you won't want to go back to bed. I have you get out of bed. You do something pleasant but not too exciting. When you're sleepy again then you can go back and do your bed and try and go back to sleep in 20 minutes. And if you're still not back to sleep then you get up and you do the cycle. It's re-training your body to associate your bed with sleep. And the key thing is you're waking up at the same time every day.

    We're not going to be compensating for things. If you had a terrible night of sleep, guess what, the next night is probably going to be better, and that will capitulate you into actually cycling normally in sleep. People often need a certain -- The first time they come in, I say, "All right, pick your wake time." And we pick it based on their sleep log and how long they can actually sleep.

    The first few days are generally very painful because people are getting up and they're like, "Oh, I barely slept last night." I'm like, "Okay, you're going to accrue what's called sleep debt." So, being awake, you're accruing sleep debt. If you take a nap, you're decreasing your sleep debt. By the time it's time to go to bed, if you have a lot of sleep debt, you're much easier to fall asleep.

    Over the course of a couple of days of bad sleep, the third day will probably then bring a good night of sleep because you're so tired from the previous days and then you can capitulate into cycling normally. But those first several days are often really hard and people need to be prepared for those. People often will ask me, "What's more important, a bedtime or your wake time?" And I say, "Oh, that's an easy question. Your wake time." We can't always control what time you go to bed because that's dependent on when you get sleepy. We can always set an alarm for when you wake up.

Christopher:    Okay.

Ashley:    Those are major pieces of the work. And then I have people do sleep diaries. We compute how long they should be spending in bed based on how long they sleep so that they're spending 85% or more of the time that they're actually in bed sleeping. We do a whole bunch of math and stuff to figure out times for people to do things.

Christopher:    Okay. Are you using electronic devices to log sleep or is it all--

Ashley:    Great question. Everybody loves all their crazy sleep devices. I'm constantly trying them out. Right now I have on -- I just got this.

Christopher:    Oura Ring.

Ashley:    I just bought an Oura Ring to see what is. I got this Whoop on over here. Comparing them. I'm always looking at all the gadgets. It's very interesting. But for treatment, what we actually really need is people's self-reported sleep log, what time you're getting in bed, how long did it take you to fall asleep, what time you get out of bed, et cetera. This is the way I can see are you spending in time in bed when you're not sleeping? Just because you're wearing this ring, I don't know if you're in your bed or you're not. I need to know that. And I trust people more than I trust these devices too at present. Plus, when you have people--

Christopher:    Oh, really?

Ashley:    Yeah. When you have people -- For the data I need. When I have people logging their stuff, they're actually learning their own patterns and they're seeing what's going on. And it's really powerful because what I hate about these devices is there have been mornings I've woken up and I felt so great. "I'm so refreshed right now." And then you look at your score and it's horrible. It says I slept horribly. I'm like, "But I feel great."

Christopher:    Not anymore.

Ashley:    No. And then it ruins it, right? And what does that do to how you feel about how you did the past night? I don't like that. I'd rather have people tell me how they did.

Christopher:    Does it not work the other way around though? Do you not get, "Oh, yeah, your sleep was fantastic last night." And you think, "I feel like shit but, I guess, the gadget says I slept--"

Ashley:    That's pretty invalidating, right? That's pretty invalidating. I don't really love that. At the end of the day, I have patients who were saying what time they physically got into bed and what time they got up and how they felt about their sleep. And then they can start to see patterns. That is the most powerful way for me to show people the association between alcohol and their sleep.

    So many people come into my groups and they're drinking quite a bit and showing them the real effect of alcohol in their sleep. When they actually look at their own sleep logs, they think, "Oh, I gave my sleep a four out of five on this night but the next night I had two whiskeys and a beer. It was a one out of five. Okay." When they see themselves producing their own data, it's way more powerful.

Christopher:    Okay.

Ashley:    Telling someone that if you stop drinking your sleep will get better does not work.

Christopher:    And people don't lie?

Ashley:    No. These people are paying for treatment and they're only wasting their money if they're doing that. And then I also make it very clear when I do their intakes with me, "Look, you're here. This is going to be really hard. You're going to hate me. You're going to want to make a dartboard on your wall and you're going to put my face in the middle and you're going to want to play darts and I can take it. I've been doing this a long time and I can take that."


    But I tell them they're always going to get worse before you get better. First two weeks, you're going to think this is not going well. I'm here to tell you that a normal graph for improvement shows a decline over the first few weeks. You're going to get worse before you're going to get better. So, I warn people pretty well that this is going to be hard. And it's a lot of motivational interviewing. That's what a lot of that session is. I'm eliciting change talk. I'm motivating them. I'm trying to help them motivate themselves based on their reasons for wanting to get more sleep to actually stick with me in this group. It also helps for them knowing that they're there and there's ten people who want their spot on the wait list right now. That's also somewhat motivating when people generally have to wait to get in.

Christopher:    As a random aside, when you do motivational interviewing, are you thinking I'm doing motivational interviewing right now or is it just a way that you operate? Is it just like--

Ashley:    It's somewhat along the lines of how I operate although in an intake I'm, of course, asking questions and getting factual answers which isn't in the realm so much of traditional motivational interviewing. But the moment that I feel like it's getting hard, that means I'm not doing it right. That means I'm not rolling with the resistance. You have to roll with someone's resistance. If you're fighting them, it's not working. You know it's not right.

Christopher:    That's very interesting. So, what do you do about external factors? I mean, the big one, I think, for most people listening will be kids, right?

Ashley:    Oh, yeah.

Christopher:    Of course, there are other external--

Ashley:    So many factors.

Christopher:    Pain is another one. People are in pain, chronic pain going on.

Ashley:    Yeah. Tons of stuff. I've run the gamut when it comes to patients with different things. And ultimately, if there's kids involved, the first thing I do is say, "Okay, how does your spouse feel about this?" If there is a spouse. "And are they behind you? Let's make a plan. Get the kids out of bed." That's often a really big one we got to do. Got to get the kids into their own bed especially when they're eight years old or ten years old. "Okay, we need to train those kids to go in their own bed because we're going to have to set times that you have to do certain things." And I'm trying to think of an example where external factors have been so strong that I've told someone the treatment isn't for them and that's never actually happened.

Christopher:    Wow, okay.

Ashley:    We've been able to work around things. I've had patients who had to fly to Africa or Beijing or whatever every month because we're in the Bay Area.

Christopher:    That's what people do.

Ashley:    It's what people seem to do. We work around that. We have to figure out techniques and plans for that and we can do that.

Christopher:    Can you fix my kid's sleep?

Ashley:    Kid's sleep. No, that's one thing I don't do. I do adult sleep. Kid's sleep, yeah, I feel like -- Your kids are little. Your kids are babies.

Christopher:    Yes. Mine are tiny, yeah.

Ashley:    They're tiny kids.

Christopher:    When I say my kid's sleep, I mean, perhaps the listeners' kid's sleep.

Ashley:    One of the interesting things about that is I've had a couple who come to my intakes and they say, "Well, my kid's sleep is a problem." Well, I'm like, "You're here. Is it a problem for the kid?" And they'll say, "Oh, he's sleeping until two in the afternoon. He's not going to bed until two in the morning and I know he structures his classes around that. These are college." And I said, "Is it upsetting to him?" And they say, "Well, no." I say, "Well, all right."

    We know that people who are teenagers tend to face later. They want to go to bed later and they want to wake up later. And as we age, we know that this shifts back. So, as we get older and older, we want to go to bed earlier and we want to wake up earlier. It's a slow and gradual movement and it doesn't -- The rate of change for that isn't equal for everybody. But it's perfectly normal for teenagers to want to wake up later and go to bed later. So, oftentimes you get parents who are in more distress about their kid's sleep than the kids are themselves.

Christopher:    But with very young children, so--

Ashley:    Very young children, I honestly don't feel qualified to comment. There's so many factors there that have to do with different aspects of the parent relationship, parent environment where the kids sleep, what the home structure is like. It's a whole different animal, pediatric sleep, than what I do.

Christopher:    And so would you just make a referral if it came in? You did my history and it was obvious that the thing that was causing my sleep was my kid's poor sleep, you'll just make a referral to a pediatric?

Ashley:    If your kid's sleep was causing your sleep problems?

Christopher:    Yeah.

Ashley:    I never had that happen, actually.

Christopher:    Oh, really?

Ashley:    Yeah. I mean, I've had people whose preoccupations about their kids have been causing their sleep problems and then I take that fine, I take that head on. That's not an issue. But if people come in and say, "My baby is colic and I can't sleep, I say--" Luckily, the person -- There's another researcher in my speech who's actually on maternity leave now but she studies sleep in pregnant women and recently postpartum women. It's a specialty that I'm really not well-versed in. My bread and butter is in young adults and adults, getting people to stop doing reactive medication use, getting people off sleep meds, and getting people back to their functional lives.

Christopher:    What about chronic pain? Say I've got a terrible back pain and that's what's keeping me awake?

Ashley:    Yeah. So, that's a very complicated thing. There's a lot of unpacking that needs to happen. But for a lot of people, looking at the fact that their pain is there whether they're awake or they're asleep is a really important step towards getting people to help themselves fall asleep. If they expect, "Oh, my pain is going to go away so I can fall asleep," that's not a very reasonable expectation.


    And this may sound a little bit -- I don't know how to describe how this will sound. Maybe just not good. But figuring out what are the environments that you're sleeping in and what's more and what's less comfortable. If people say, "Nothing makes the pain better," I say, "Okay, nothing makes the pain better. What makes the pain worse?"

Christopher:    I'm very good at this as well. Via negativa. If you ask me what I want I can't tell you but if you ask me what I don't want I've got a whole long list of things I could tell you.

Ashley:    So, it's worse when you're in soft bed than when you're in hard beds. Okay. So, that doesn't mean that hard beds make it better but that means soft beds make it worse. You can think about things you have to put on the patient's shoes and really see things like they're seeing them. For a lot of people with pain and sleep problems, it's getting the medication used right is key. Because there's so much reactive medication used.

    People will often sleep poorly one night and make decisions based on one poor night of sleep. If I diagnose people with or without clinical insomnia based on one night of sleep, I'd be a horrible diagnostician. Horrible, right? So, when I look at someone's sleep, I look at a seven-day period to see, okay, bad nights, good nights.

    Because if I catch you on a good night and you have a problem with sleep and you haven't slept several nights prior and I just did that one night that was good, I'd say you certainly don't have a problem. So, looking at multiple nights together helps that. And when people have pain problems and one night they have a good night and one night they have a bad night, they might make an entire routine changes based on minute changes in their pain, that could be perpetuating problems.

    So, getting set routines, getting the medication regimen down so that we're not doing so much reactive use, those are my first steps when I'm thinking about pain. And most of the time when people have presented to me with pain and sleep problems, it's been pain following from, oddly enough, shoulder surgery. Rotator cuff surgery is a popular one, a really popular one, and some sort of back problem. Those are the two most common ones. Arthritis, I guess, is another one that comes up a lot. Getting routines and medications right and their timing is really important.

Christopher:    And how much of a role do you think will this other stuff that I just glossed over there that we talked about on the podcast before, how often is CBT not necessary? You just need to stop using your, being exposed to so much light at night, not enough light during the day, food timing, movement timing, maybe even socializing timing, all of that stuff. Do you ever have a patient where you're like, "You just need to sort all of that out and you didn't really need any of the CBTs." Does that ever come up or is that not a thing?

Ashley:    It depends on how much you incorporate of that into CBTI and I actually incorporate quite a great deal of it.

Christopher:    Because you don't make a distinction.

Ashley:    I wrap it all together. Some people are pretty light sensitive folks. Other people less so. Do I tell people to strive for bright light in the morning when they get up? Oh, yeah. Do I try and tether that to a behavior? Oh, yeah. "You love getting your mail? Great. You can't do it at night anymore. You can't have your mail until the next morning." So, you bet people are jumping out of bed because they want to get to their mail box to get their mail. That tends to work for people who are a little bit older in my groups.

Christopher:    I don't seem to get anything good in the mail anymore.

Ashley:    I know. But some people, they really still. They love getting their mail. But taking dog on a walk early in the morning, doing things that get them outside is really key. Again, in debates with folks about sunglasses. They want to wear the sunglasses 24/7 outside. I try and get them to take them off a little bit in the morning. Let's get some actual light exposure happening in the retina a little bit.

    Some people lecture me about glaucoma and macular degeneration and all of this stuff. I'm not an expert but it does seem that it's important to get some light in the morning. So, try and do that. I've only had one patient who found that all he had to do was stop using the computer for four hours before he went to bed and it solved all his problems. But I've only had one patient for whom that was true.

Christopher:    Okay.

Ashley:    There's a lot of these blue light filters, all these fancy things. I've had patients tell me all the millions of fancy things they do and then I say, "Well, what do you do in the middle of the night when you wake up?" They say, "I meditate in bed." All those fancy things are not really what you need. What you need to do is not meditate in your bed because you have to sleep in your bed. You can meditate in your couch." You're associating your bed with meditation.

    One of the quickest ways I can figure out what's going on is if I say, "Do you sleep better when you go on vacation or when you travel for work?" People say, "Oh, yeah." And I'm like, "You don't have associations with the beds in those hotels. You do with your bed at home. You associate your bed with not sleeping." So, all those fancy things are fun. Do I think that finishing eating significant amount of time before you go to bed is ideal? Absolutely. I totally love Rhonda Patrick's podcast with Satchin Panda and all the--

Christopher:    Satchin's been on our podcast as well.

Ashley:    Yeah. I love that stuff.

Christopher:    [0:59:37] [Indiscernible] she did a good one with it as well.

Ashley:    I love that stuff. I think that the circadian eating is just wonderful and it works. However, when people come to me for CBTI, I have to fry a bigger fish first and that's generally wake time, stimulus control, sleep hygiene, the basic tenets of that. When people get further along and they want to do other advanced follow-up stuff with me, yeah, I'll get into some of those things.


    I'd say that the biggest bugaboo that I seem to come up to in the Bay Area with that is people want to wake up at like 4:30 in the morning to go to a 5:00 a.m. workout class and we just have to really go over what's a healthier choice for you. Is that really required? Could you do something else?

Christopher:    It's hard though, isn't it? I'm so lucky in that I work for myself and I set my own schedule and I don't commute anywhere and I can choose to go ride my bike at 1:00 in the afternoon. I feel very privileged for that. But it seems for some people there's not any good choice. Either I get up at 5:00 a.m. and do this thing, or even earlier, as you pointed out, or I do it after work and then if you're doing some high intensity interval training at 8:00 at night, that's probably going to affect your sleep as well. Cortisol has a half life of hours.

Ashley:    Sure, sure. Whenever I ask people now about the timing of their exercise, I'll never forget one. So, I said, "What exercise do you do?" This person told me, "Oh, I go to the 10:00 spin class near Castro." I assumed that was in the morning. And so I've since learned that those spin classes can be darn late and so now whenever people say, "Oh, 10:00," I'd say, "Is that a.m. or p.m.?" They look at me funny. I'm like, "No, I'm really asking you that." I really am.

    It's really tricky when you're really busy. And figuring out how to fit more movement into your day throughout the day and not just conceptualizing if I don't go to the 60-minute class I did not exercise today. This black and white thinking isn't going to get you anywhere. Can you park further away? Can you take the stairs? Can you stand up every now and then in your meeting?

    We're standing up right now and we're chatting. There's all sorts of ways to fit it into your day and maybe it just so happens that you don't have time to go to those classes until your days off or days where you have half days of work or you work from home one day a week or maybe it's a Sunday. So, figuring out how to work that all into your schedule is the eternal challenge because of the American way of work.

Christopher:    Right. Can you tie this back to the clinical trials that you've done? So, how does this -- I mean, have you ever had a study where you wanted to look at a low carbohydrate diet as an intervention and you thought, "How the hell am I going to get people to do that if they're not sleeping right? Can I do the sleep thing too? Or can I do the sleep thing first?"

Ashley:    Currently, my sleep work is all clinical work. None of it is in the realm of research. None of my patients are enrolled in any sort of trial. They're literally just there to get better. It's my happy clinical place. In our trials for type II diabetes where we teach the carbohydrate restricted diet and the mindful eating stuff, we do address a number of lifestyle factors ranging from how to eat at restaurants when you're out with friends to how to plan for travel to why go to bed.

    We don't do full blown sleep treatment with them but we do give basic here's why sleeping might help you with what you're trying to do information. I wish it was a little bit more linked but when it comes to doing research and treatment, you generally fry the biggest fish represented with. Some people come for sleep problems in my clinic, that's what we're working on. People come for type II diabetes interventions, we're working on the diabetes, even though in the perfect world we know this is all related. I mean, ideally, we could do it all at once but that's just not the way the system is set up. It's unfortunate.

Christopher:    Well, I think you're doing some fabulous work and I'm very excited about all of it. Congratulations on everything you've achieved over the last five years.

Ashley:    Thank you. It's a wild ride. I'm having a great time. We'll see how long it lasts, the way that the government are funding structure is and how all of this goes. I think that research could see a huge change in the next decade.

Christopher:    Oh, really? Now you said it, what do you think that change might look like?

Ashley:    I haven't the foggiest but I do think that the way that people go about doing research, all this grass root crowd funding, all these different ways of funding research that aren't necessarily government and aren't necessarily industry, I'm hoping to see some more of them.

Christopher:    It's just the numbers you need to get to though. Like I was bullish on the idea too. There's even websites now where you can crowd fund your experiment, experiment.com.

Ashley:    Oh, wow. I didn't know that one.

Christopher:    Yeah. Richard Feinman and the others have done some crowd funded experiments. I mean, how much does, some of the clinical trials that you've been involved in, how much did they cost? You're talking about millions of dollars, right? You can't crowd fund--

Ashley:    They're expensive. Yeah, they are really expensive. And it's a significant challenge because the National Institute of Health can only fund so much research. And in order to get a trial funded, there's so much you have to do beforehand and that will cost money. That will cost time. I don't know exactly where it all is going to go but I do think that being at UCSF, which is a major medical research facility, and seeing how there's people who are purely government funded researchers, there's a lot of ties with industry, there's a lot of collaboration with industry, I think a lot of those kinds of designs will become more popular and I just hope that we maintain ways of -- what's the word? The opposite of opaque. Being very clear and showing conflicts of interest is going to be, I think, an emerging concern in research as more and more non-government agencies get involved.


Christopher:    Interesting. Well, I will, of course, link to a list of your publications in the show notes for this episode that you can find at nourishbalancethrive.com/podcast. Where should I link to so that people can find you online? Of course, you're going to tell me that your sleep clinic has got a three-year waiting list or something. I'm in the Bay Area.

Ashley:    Well, it's not a three-year waiting list but it's a little bit of -- It's a month. People can learn more about my lab at beelab.ucsf.edu. That will be changing soon. We're changing our name to be the SEA Lab, sleep, eating and affect. That's what we do, a bunch of those things now so we're changing. To learn more about my sleep work, it's Osher's Sleep Group at ucsf.edu.

Christopher:    Is there any book you should recommend for CBT for sleep? Is there any good book? Or is it really you're going to go find a clinician?

Ashley:    Well, I think for some folks they need a clinician because when they read the book they think, "I can't do this myself." But I do have a favorite book. And it's by Dr. Rachel Manber. She's at Stanford. It's called Quiet Your Mind & Get to Sleep. It's on Amazon. It's not overly expensive. The foreword is written by Dr. Richard Bootzin and that's the person who taught me how to do this treatment at the University of Arizona while I was doing my PhD.

Christopher:    Wow. I look forward to reading that.

Ashley:    Yeah. It's a good one.

Christopher:    I'd like to change the title slightly to make it a bit more sweary. Can I do that?

Ashley:    You might sell more books that way but I don't think an academic would title their own book that way.

Christopher:    You say that but we work with performance psychologist Simon Marshall and his book was called the Brave Athlete: Calm the Fuck Out and Rise to the Occasion.

Ashley:    That was a bold title. That's a bold title. I hope I get bold like that someday. We'll see. I got a few years left.

Christopher:    Well, thank you so much for your time. I very much appreciate you.

Ashley:    You're welcome. It was a pleasure.

Christopher:    Thank you.

[1:06:58]    End of Audio

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