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Scot: The Core Four and some basic strategies around nutrition, activity, sleep, and mental health can go a long way to help us be healthy and feel good today and in the future. But sometimes those basics aren't enough. And today on "Who Cares About Men's ÑÇÖÞ×ÔοÊÓƵ," the topic is "Sleep, It's Complicated."

Sleep, of course, is one of the Core Four and it's critical for good health, and it can be really frustrating when you're not getting the sleep you need. And today on the show, Mitch is going to talk about how he had to go beyond the Core Four to address some of his sleep struggles, on his journey to getting more quality Zs.

This is "Who Cares About Men's ÑÇÖÞ×ÔοÊÓƵ," providing information, inspiration, and a different interpretation of men's health. I'm Scot Singpiel. I bring the BS. He brings the M.D., Dr. Troy Madsen.

Troy: That's right, Scot. I had no idea sleep was so complex, but we're going to see how complex it is.

Scot: Just trying to stay awake, it's Producer Mitch.

Mitch: Every day, just trying to stay awake. And hopefully, we can talk a little bit about that today.

Scot: And our expert today, Dr. Kelly Baron. She's a behavioral sleep medicine expert at the ÑÇÖÞ×ÔοÊÓƵ of Utah Sleep Wake Center. And her response to . . . Well, we'll save her response to Mitch's sleep study that he took for a little bit later on the podcast.

Did you know, Troy, that Mitch . . . Doing a podcast like this, you learn a lot about somebody. Did you know that Mitch likes running a true crime podcast? Did you know that?

Troy: I actually did know that, yeah.

Scot: And he's trying to build up his vinyl collection. We've learned that about him. And when he sleeps, he starts out on his left side. Then he's on his right side for a short time. Then he's prone for a bit, and then supine for a bit, and then he ends up back on his right side. That's according to his sleep study. He also has a sleep efficiency of 75%. Is that good? I don't know.

Mitch: I don't know either. It doesn't feel good.

Dr. Baron: Yeah, how does it feel?

Troy:It's a passing grade.

Scot: Dr. Baron, you're trying to get in among the three guys. We're going to be quiet and let you say what you wanted to say.

Dr. Baron: So in a sleep study, you're coming to a lab and it's just one night. So I would caution you to over-interpret something like sleep efficiency. Sleep efficiency is the amount of sleep divided by the time in bed. And so on a sleep study, they might be like, "Hey, it's 8 p.m. Get into bed. Let's start this recording." And you're like, "Okay, I guess so," and you might spend two hours trying to get to sleep because you normally sleep at 10 or something like that. So that number can be a little bit influenced by the characteristics of how the study is done.

Now, in this case, your sleep period started or your recording period started about almost 10, like 9:40 or so. And so I think the sleep efficiency number also reflects how much you're awake during the night.

So it is one measure of how consolidated or consistent your sleep is through the night. But it can go up or down depending on how they run this study. Yours is not good, and it's consistent with your experience in your sleep.

Troy: Regardless, it's not good.

Mitch: It's just not good. All right.

Troy: It's not good.

Mitch: Here we go.

Scot: It's going to be a fun ride today, isn't it, Mitch?

Mitch: I know. I'm so excited.

Scot: On "Who Cares About Men's ÑÇÖÞ×ÔοÊÓƵ," of course, sleep is part of the Core Four, and we've done a couple of episodes talking about sleep and if you're not waking up refreshed, or you're having a hard time going to sleep, or if you're waking up during the night, some of the basics.

Now, Mitch, tell us about your experience with sleep.

Mitch: When I first started getting involved in this podcast, and we were talking about the Core Four and stuff like that, sleep was always one of the ones that I had trouble with, right? I've had a long history of insomnia, of not being able to fall asleep, not being able to stay asleep, etc.

And so after we did the first couple of episodes, I'm like, "You know what I'm going to do? I'm going to do it. I'm going to focus on my sleep hygiene. I'm going to get into a rhythm and everything." And for the last year or two, it's been go to bed at 10 or 10:30, make sure I'm not playing on my devices after a certain time. I got a fancy-schmancy sleep mask because that's what Troy told me I should do.

I did everything I possibly could. I'm waking up at the same time. If I can't sleep, I get up for a little bit and go back. I was doing everything I possibly could. I even got a little app about cognitive behavioral therapy and sleep to make sure I'm not having sleep anxiety.

I was doing everything and I still woke up feeling miserable every day, right? I was still tired. I was still trying to pound coffee just to get through the middle of the day or whatever, right? And I recognize that could also be a problem and I cut that back, but it just was all the time tired, tired, tired.

And so over the last year with dealing with my fatigue problems and everything like that, while I was looking at testosterone, while I was looking at mental health stuff, I was also looking at what is going on with my sleep, because it is so important.

What the "It's Complicated" series is all about is sometimes it's a little more complicated than just "Do better."

Scot: Yeah, or you do the things you're supposed to do and it doesn't feel like you're really making any progress.

Dr. Baron, what you're hearing from Mitch, is that common? What's your take on what you just heard right there?

Dr. Baron: I mean, first of all, you did all the obvious things, and it can really leave you feeling just kind of helpless or even feel kind of like, "Well, maybe this is just all in my head." And so I think your experience is really common.

And this feeling of unrefreshing sleep or afternoon fatigue, it really is . . . A question is "What could this really be from?" It could be from a lot of different disorders, and that's really the difficult thing, is where to turn. And we do see a lot of patients who have that sort of fatigue or sleepiness.

So a question I really would have is did you feel like it was sleepiness, that you felt drowsy and couldn't stay awake? Or did you feel that it was fatigue or mental or physical tiredness, or both of those things?

Mitch: Yeah. So they were pretty mixed together until recently. We had an episode where I worked with a men's health specialist who diagnosed me with low testosterone/hypogonadism. And once that got fixed, a lot of the physical fatigue had disappeared and it was like, "Oh, okay, so my hormones were all off. That makes sense." But it didn't solve the tiredness.

I was feeling sleepy. I was dragging. I was feeling like I needed a nap in the middle of the day. And it wasn't the same kind of physical tiredness like I had before. It's a lot in the head, and just feeling like I needed to go back to bed all day long.

Dr. Baron: That's really interesting. In my clinic, in the Behavioral Sleep Medicine Clinic, I tend to see mostly people with insomnia. And so it's the difficulty falling asleep, staying asleep, waking up too early.

But sometimes we get through the whole cognitive behavioral therapy, and they don't see sufficient improvement. That's when we would say, "Let's do a sleep study." If they don't have any obviously apnea symptoms, we'll say, "Let's treat the insomnia, and then if needed, we'll do a sleep study later." We don't need a sleep study to say you're not sleeping. Insurance is like, "We believe you. We don't need a study."

But for those patients, we will do a sleep study to look exactly at what you did. You're like, "I did everything I thought I should do and I still don't have good sleep. What is going on here?"

Troy: In hearing this, too now, Mitch, you recognize the problem. How did you actually end up in a sleep lab? Did your primary care provider refer you, or did you just call a sleep expert? How did you get to that point?

Mitch: I had been working with my PCP. And after we had figured out some of the testosterone and the mental health stuff, it was now down to, "Hey, man. I'm still feeling tired all day." And he's like, "Well, let's do a basic at-home apnea test. Let's try that out and see how your sleep is doing." And the results came back medium, right?

But it was enough of a negative result that he's like, "Hey, we should get you in. Let's at least clear the decks. Let's just at least make sure that you don't have apnea, all these other things are going on before we continue troubleshooting."

That's basically what it sounds like these days. It's like, "Hi. Things aren't working. Have you turned me on and off again?" It's just so frustrating.

Finally, what happened was the first test was done. It came back with middle-of-the-road results. And he's like, "All right. Let's go ahead and try out the full thing. Let's get you all hooked up and just make sure that there isn't anything super serious happening with your sleep schedule."

Troy: Yeah. So it just sounds like it at least raised a little concern in your primary care provider's mind that they wanted to get the full study.

Mitch: Yeah. So they send you home with this little armband and finger thing or whatever. And basically, the results said, "Could be apnea." I don't know. I can't read it. I don't know what the . . . But it was just like, "There is . . ."

Scot: It sounds like it was a Magic 8 Ball they gave you. "Could be apnea."

Mitch: "Maybe."

Dr. Baron: Was it just oxygen levels or did it have a chest belt as well?

Mitch: It had a chest belt as well.

Dr. Baron: So you did a home sleep test, which is really the first step for most patients. That's what insurances want people to do first these days. And I think a lot of patients prefer it. I think a lot of patients are kind of relieved when you say, "Oh, you can take this and just strap this around your chest and put this on your finger and wear it at home," versus spending the night in the lab.

And the research really shows that for someone with moderate to severe apnea, they're very good at picking that up. And it reduces barriers that someone with kids, for example, doesn't need to find ÑÇÖÞ×ÔοÊÓƵcare. It's a little bit less burden to the participant. It's lower healthcare cost as well. And they do just as well on CPAP treatment if they have sleep apnea and they did the home test. It's not like they missed having that experience in the lab.

And so I think that lowers a barrier for patients. But as you're pointing out here, it didn't show that you had apnea, but perhaps it showed a little bit of desaturation or a couple apneas that maybe they thought they wanted to have a more in-depth study in the overnight test in the lab.

Troy: It is really good to hear about that home test too. I'll say personally that's a big barrier for me. The thought of going to a lab, an unfamiliar environment, and being hooked up to all these different probes and everything and feel like you're being watched all night. That just seems weird. I'm going to be curious to hear what you experienced, Mitch.

Mitch:Oh, it was weird.

Troy:The home test sounds good. That sounds doable.

Scot: So after the home test, then it was recommended that you go and do a sleep study. What was that like? Now, that's where you actually have to go somewhere else and they hook you up to a few more things, don't they?

Mitch: Yeah. I think I sent you a picture I had the nice technician take a picture of me after I was all hooked up. But it is a bit intimidating. You go to this lab and the person . . . It takes like 20 minutes to get everything on. There are chest straps and back straps, and they have all these wires that they're running on. They put all this stuff through my hair and on my scalp. They're taking these little bits of sandpaper-y type thing and making a spot on my head and sticking all these probes on.

And then the next thing is like, "Well, we'll watch you and we'll be able to talk to you."

Scot: "Good night."

Mitch: "Crawl into bed with all this stuff. Give me a holler if you need me to disconnect you to use the restroom, but good night."

Scot: Wow.

Troy: That sounds so awkward.

Mitch: I don't know who picks the decor up at The U stuff. No shade, it's a wonderful center, love them, but it was an obviously haunted photo in my room as well. Three ghostly Victorian women with their heads on their shoulders. I'm like, "Not okay."

Dr. Baron: I did my training there in the early 2000s and that place has not changed one bit.

Troy:Oh, wow.

Dr. Baron:And it probably hasn't changed since they put those photos in, in the Victorian era. I mean, it's meant to look like a sort of hotel room sort of place.

And I do like to tell my patients that we're not expecting the best night of sleep of your life. We're really expecting to just get a couple hours of sleep to know how your breathing is going. And so it kind of takes the pressure off, but it's uncomfortable. You're hooked up, you're in an unfamiliar place, and it can be a little bit unnerving.

Troy: I will say, too, hearing this I have stayed in a hotel that is in the top 10 list of the most haunted hotels in the U.S. Your decor sounds a lot like that hotel.

Mitch:But it was really a great center. I don't want to disparage it at all. It's just it was a weird painting to try to sleep with.

Troy: These Victorian women looking at you.

Dr. Baron: There's a whole genre of sleep art and a lot of these paintings depicting these Victorian women with demons or that sort of thing. It's thought that a lot of these sleep disorders were interpreted as hauntings or demons or things like that. There are things like sleep paralysis they're depicting where you wake up, you know you're awake, you can't move, or hypnagogic or hypnopompic hallucinations, that you kind of see things as you're drifting off to sleep or as you're waking up.

So there are some really famous paintings, like one called The Nightmare where there's a demon is sitting on someone's chest. Sleep people love that stuff.

Mitch: So, yeah, you just curl up with all your wires and fall asleep eventually. And then next thing I know, I'm being woken up, very kind voice being like, "Hi, I'm here to unhook you." And then you go about your day and wait to hear from the doctor to read the results.

Scot: Yep. And then you get three or four pages of information here, it looks like.

Mitch: Yes.

Scot: Mitch sent Troy, myself, and Dr. Baron the results of the sleep study. And we're all playing pretend sleep experts.

Troy: Well, two of us are playing pretend sleep experts. One of us is an actual sleep expert. Two of us are like, "Yeah, I'm just picking out this stuff. Oh, wow, look at your oxygen levels. Oh, wow," which probably is completely meaningless. I have no experience interpreting this, but I found it fascinating.

Scot: I don't know where to go from here. I don't know if I should just ask Mitch what were you told? I don't know if we should ask Dr. Baron what she's seeing. What do you think we should do next?

Mitch: So I guess the main takeaway was that . . . I do have a family history of sleep apnea, right? There are CPAPs in my family. And so it was like, "Okay, maybe I have apnea. Maybe I need to figure that out." I was preparing myself for that.

Scot: Yeah. Hold on. Let's jump in here. Dr. Baron, what is sleep apnea in the 30-second version? What does that even mean?

Dr. Baron: So sleep apnea is a diagnosis made by showing that you have repeated pauses or blockage in your breathing at night. And so they're 10 to 30 seconds long usually, and then you wake up and you start breathing again. So it's a partial or complete closure of the airway.

Scot: So it's a breathing thing that not only doesn't sound great, but it's . . .

Dr. Baron: I should clarify there are two types of sleep apnea. There's obstructive sleep apnea, which is pauses in breathing due to the closure of the airway, and then there's central sleep apnea, and that's when the brain has pauses. And that happens, for example, in heart failure, with opiates, and that sort of thing. So there are two different kinds, but obstructive is the most common kind.

Mitch: Got you.

Scot: So is that what you ended up being diagnosed with, Mitch?

Mitch: No, surprisingly not.

Scot:Even though it's in the family? All right.

Mitch: As terrible as it sounds, there was a part of me that was like, "All right. My family's dealt with this before. I just get a CPAP machine. It's not the most exciting thing in the world, but I'll just do it and I'll sleep better and everything will be great." But no, that's not what the results said.

Scot: Not only that, but it doesn't even look like you snore.

Mitch: Nope, not a snorer.

Scot: Go ahead and put that on your dating profile.

Dr. Baron: The main signs of sleep apnea are snoring, as you pointed out. Snoring, daytime sleepiness, unrefreshing sleep. But there are also people who can have sleep apnea and not snore, and they can just kind of have some gasping or pauses in their breathing. And so we often ask them to ask their bed partner, if they have one, if they've heard them pause in their sleep. That's a big sign of it.

But otherwise, you also can just have sleep apnea and be unrefreshed from your sleep or be depressed or irritable. It can really come out in a lot of different ways in how it affects you. And even sexual dysfunction. There can be erectile dysfunction, low libido. It can affect testosterone.

So there are a lot of different ways that sleep apnea can affect somebody. Not everybody with sleep apnea snores, but it is obviously the most outward symptom of it.

Scot: Yeah. On this study, though, it doesn't even show that you snore. So what was it?

Mitch: Apparently, my leg moves a lot. Dr. Baron, how did you respond to the email I sent you showing you my results?

Dr. Baron: Well, there's a little graph at the bottom. I said, "Holy moly," because there's a little graph. There's a picture of it at the bottom, the events throughout the night. It's blue when you have an event, and literally your entire night is pretty much all blue.

Scot: It's like a solid blue bar. It should be little lines here and there.

Mitch: Little lines, yeah.

Dr. Baron: Your legs are twitching all night long. And not only are they twitching, but it's waking you up. So each time you have a twitch, they've also scored an arousal in your EEG of your sleep recording.

It's quite substantial. You had total limb movements 524 over the night, which is a lot. But you look at it per hour, and so number of limb movements per hour, that's 83.6. And the number causing arousal is 27.3.

Scot: And I take it by your "holy moly" that's not usual. That's not something you normally see me.

Dr. Baron: We would consider it elevated if it's above 10.

Mitch: Oh, my.

Troy:Ten per hour?

Dr. Baron: Yeah. But keep in mind, limb movements themselves, or if somebody is kicking their legs at night and it's not bothering them . . . It's kind of this weird thing. We're unsure of the clinical significance of limb movements unless it's causing a daytime impairment.

Most people who have limb movements also have a subjective feeling of restless legs. And so I was going to ask you that as a follow-up. Do you have a creepy crawly urge to move your legs in the evening?

Mitch: I've had it on occasion. It's never been something super serious. It just comes up occasionally. But we can talk a little bit more about what could potentially cause it, I guess, is what I'm kind of curious about. Everything is complicated and connected.

Dr. Baron: Yeah. Actually, I don't even know what causes periodic limb movements. I mean, there's something in the dopamine pathway related to it. But most people who have this level of movements will have a subjective experience of restless legs.

But the point of treating the legs is really only worth treating if somebody feels like their sleep is bad quality, in your case. Otherwise, it's not clearly related necessarily to a health risk, having your legs kick at night.

There are some studies showing an increased risk of cardiovascular disease, but it's not really consistent at this point. It's really to understand whether the limb movements themselves are problematic. Unless you feel bad, and then that's clearly a target to address.

Troy: Sounds like in Mitch's case there was clear evidence it's affecting his sleep. You said 27 movements per hour that were disrupting sleep? Is that what the report said?

Dr. Baron: Yes.

Troy: It's like every two minutes you're waking up because your legs are moving. That's impressive.

Mitch: Yeah, you got it.

Troy: Wow.

Scot:Just to clarify, while you're trying to fall asleep, you don't have necessarily restless legs. You don't have this need to move your legs.

Mitch: I would have it maybe once or twice a month. It was never a big thing. There is a genetic side to it or whatever.

But one of the things that was interesting is my sleep doctor brought up . . . Speaking of the dopamine pathway, guess what is a potential side effect of some of the anti-anxiety meds I'm on? It's maybe an increased rate of restless leg syndrome or occurrence of restless leg syndrome.

It's like a whack-a-mole problem with my health sometimes where it's like, "Great. So we figured out mental health stuff, but is it making my sleep worse?" So we're trying to figure out one thing or another.

Man, oh, man, I was just shocked. Like I was saying before, I almost wish it was apnea because then there's a clear path forward, but it's just more complication. And it's just like, "Okay, what else do I have to do to get a decent night's sleep?"

Dr. Baron: That's true. Now, I think all of the SSRIs are related to restless legs or limb movements, but Wellbutrin is one that's not. So not all of them are. Some more than others.

Mitch: Right. And so now we're like, "Now we're playing with the brain chili," as our wonderful mental health people talked about. We've got to go back to the drawing board on this thing. So anyway, it's very interesting.

Dr. Baron: The most interesting thing to me about the drugs that treat restless legs or periodic limb movements is that you kind of get to choose one or the other. The drugs either quiet down the brain arousal . . . So either it's a benzo that makes your brain more stable at night and you're kicking, but you're not waking yourself up, or they're the more dopamine-type drugs. Those keep your legs from kicking, but then you still have the brain arousal. Isn't that interesting?

Mitch: Yeah, it is. Interesting and fun.

Dr. Baron: They both improve the symptom, but they do it in a different way. No drug does both of them. I think the most common drug used, the most recommended drug used is Gabapentin.

Mitch: And that's what they've got me on. So the treatment moving forward is, one, work with my mental health person to maybe look at my mental health meds, and is there something we could try differently that might minimize having just that many "holy moly" amounts of leg wiggling? So we're messing around with that. I'm on Gabapentin. And then I do some little yoga stretches before bed just to try to calm the legs and make sure that everything is relaxed before I go to bed.

Troy: And have you noticed a difference yet?

Mitch: We've been doing it for about a week. It hasn't been too long. These results are relatively recent. But it's been a week. I haven't noticed a big shift yet, but I'm told that it can take a while for the drugs to build up in your system. It can take a while for your body to get used to the stretching. So I'm trying it out, working with my doctors, seeing what's next.

Scot: So then you're trying out some stretches, some medications. What's the next step, then, to see if this works? Is it just simply are you waking up more refreshed and bing, bang, boom, we've got it? Or are you going to go back in and they're going to check your leg movement again during a sleepover study?

Mitch: Well, we're going to first try some stuff for the next couple months, is what I've been told as it can take some time, to see if we can improve my general sleep quality.

But because of just how much movement I was experiencing, my doctor has suggested within the next year going back in, getting hooked up, sleeping underneath the spooky pictures, and going back to just one more time make sure that things are actually getting better physically, just because of how much leg movement there was in this situation.

Scot: Dr. Baron, I have restless legs, where sometimes it prevents me from falling asleep. And then eventually I do. My wife then will comment, sometimes even while I'm sleeping, she'll go, "Oh, you were kind of twitchy last night."

Am I understanding correctly that restless legs like that wouldn't necessarily always impact your sleep quality? Because after hearing Mitch's story, I'm like . . .

There's something you've got to know about me, Dr. Baron. I'm always looking for what's my thing. Why am I tired all the time? Why am I lacking energy? I'm doing all these things. "Nope. Normal, normal, normal." So now here's my new one thing. Would my restless legs potentially be causing me not sleeping well, too?

Dr. Baron: So do you remember that . . . There used to be a commercial that said, "The most common disorder you've never heard about." Remember that one?

Scot: Yeah.

Dr. Baron: So that's restless leg. And restless leg now is going by the more complicated title of Willis-Ekbom disease. We feel like a lot of people don't take it seriously, and they say, "Oh, you just kick your legs at night." But obviously, you guys both know the impact on your quality of life.

So just to go over the criteria for restless legs, it's an uncomfortable, creepy-crawly sensation in the legs that is relieved by movement. And it also has come on in the evening, so it's specific to the time of day.

Troy: Does it have to be every day you experience it, or once in a while in terms of timeframe?

Dr. Baron: I mean, a lot of people experience it occasionally. I even experienced it like when I'm really overly tired or have jetlag. The worst is a very late-night flight. I'm so restless. And it's also worse when you have to stay still.

They used to have a test for restless legs, an objective test, where they used to record people and say, "Stay still," and then count how many times they moved. It sounds like torture, but it is a really torturous feeling.

I mean, the severity is related to how much it disrupts your sleep, how many times a week you have it, how much you feel like it impacts your daytime, that sort of thing.

So somebody experiencing it once or twice a week, or once or twice a month, that's on the more mild side. But somebody who is saying every night it impacts their sleep, that's on the more severe side.

Scot: I guess my question ultimately is, let's say, out of a week, maybe it bothers me falling asleep three nights out of the week. But I always just assumed after that then, "All right. I've fallen asleep. Restless legs aren't an issue anymore." But clearly, what we're seeing here with Mitch is that's not the case, right? They can wake you up in the night and you might not even know that that's what's happening.

Dr. Baron: So just to separate, though, there's the subjective experience of your legs, and then there's the objective kicking. And they don't always go together. As a clinician, I'm most interested in the subjective. So I'm most interested in how much is it bothering you when you fell asleep, or if you're unrefreshed during the day.

Scot: Got it.

Dr. Baron: I guess if you're having trouble falling asleep three times a week because your legs are uncomfortable, I would say that crosses a threshold of going to talk to somebody. So maybe this is your thing too.

Mitch: Hey.

Troy:We got something for you, Scot.

Scot: Yeah, maybe. I'm always disappointed, though, so I plan on being disappointed here too.

Dr. Baron: Restless legs, though, doesn't require a sleep study.

Scot: Oh, okay.

Dr. Baron: Because if your legs are uncomfortable, then that . . . Unless you have signs of sleep apnea or other indications, do a sleep study. If your legs are restless, that's a sign that you could have a treatable condition. Then just treat it. You don't have to treat it and then follow the impact objectively. It's more about how you feel during the day or how much your legs bother you at night.

Scot: Yeah. Well, for what I'm looking for here is, like I said, I tend to feel like I'm tired a lot, right? So I'm looking at what could possibly be causing that. And I hear that restless legs or leg movement in the middle of the night could be the problem.

Up until this point, maybe on a night where I have restless legs it puts me going off to sleep for 15 minutes extra. But after I fall asleep, I assume that they're not impacting me anymore. Is that a safe assumption? Or could they be still going and I don't realize it, causing these little micro-wakeups like Mitch was experiencing?

Dr. Baron: Yes. It's highly likely that you're having that because about 80% of people who have restless legs also have these limb movements at night. I mean, it's so common when people have restless legs that they don't even necessarily need to do the sleep study to document them.

Mitch: Wow.

Troy: And if someone's listening or maybe Scot wants to try something before trying medication, what would you recommend?

Dr. Baron: Interestingly, for restless legs, it has really the most folk treatments of any disorder. I don't know if you've heard about the bar of Ivory soap under the bed.

Troy: No.

Scot: I was really kind of hoping for something tastier.

Troy: Ivory soap.

Dr. Baron: I mean, there are some people who have tried magnesium, for example. And then iron can improve restless legs as well. And that's really the first line if it's indicated, because it is more safe, less side effects than going on to medications.

Scot: As with these episodes and talking about health, a lot of times one man's experience then kind of morphs into another man's experience and then it starts asking questions like here. But let's get back to Mitch briefly. Is there anything else looking at this sleep study that you noticed, Dr. Baron, that you'd like to bring up?

Dr. Baron: Well, we were talking about the sleep stages earlier as we are going through this together and . . .

Scot: Yeah, and actually, I wanted to jump in because we had a talk with you about these sleep trackers that you can get that allegedly tells you how many minutes of REM sleep you get. And we discussed whether that's the gold standard or not, which it's not.

But what was Mitch getting for REM sleep? Thirty-nine minutes? Thirty-three minutes, yeah.

Dr. Baron: Thirty-three, 8.8% the night. Again, you have to take the sleep study stages with a grain of salt, because, again, it's not your normal environment. You're going to sleep a little bit earlier. How different is the timing of the sleep, from 9:40 to 6? Is that pretty consistent with when you sleep at home?

Mitch: I usually do 10 to 7, so it wasn't that big of a difference.

Dr. Baron: Okay. So it's similar, but the thing with REM sleep is you get the most and the early morning hours. And if you have a 20-year-old in the sleep lab and you wake them up at 6, well, that's the middle of the night for them. They're getting their REM usually later, like 8, 9, or 10 in the morning, for example, if they're a later sleeper. But in your case, this was aligned with your normal sleep.

It showed that only 10% of the night was in deep sleep and 8% was in REM sleep. And the REM sleep number was really lower. That should really be about 20% or 20% to 30%.

And as I look at your hypnogram, which is the picture of your sleep, to me, it really suggests that the leg movements are interrupting your sleep stages. And so you can see how even sometimes you get into REM and then it just wakes you up.

Mitch: I see that, yeah. The line goes from what? It's deep sleep, REM whatever, and then at the top is awake, and I keep bouncing right back up to awake.

Scot: How does this compare with your fitness tracker?

Mitch: The fitness tracker made it seem like I was sleeping better.

Scot: Oh, okay.

Mitch: The numbers that they gave me are much lower from the actual sleep study than the Fitbit that I wear.

Scot: Got it. Well, Mitch, I guess as with other aspects of health, you've proven our hypothesis of just focus on the Core Four. Sometimes it's a little bit more complicated. When can we get an update, did you say?

Mitch: They said a couple of months to try the Gabapentin and the stretching and everything. So yeah, we will bring Dr. Baron back on and we can chitchat about how it's improved.

I hate to blow up the Core Four, but man, oh, man, if you are someone out there that you're hitting your head against the wall being like, "I'm doing it. I'm doing the sleep journaling. I'm doing all of this stuff and it's still not working," maybe you have shaky legs. Maybe you have some chemical imbalance. Maybe you've got who knows, right? Maybe there's something else going on.

Scot: Dr. Baron, to wrap this up, how long should somebody try to do the things that are generally recommended before they kind of take the next step that Mitch took?

Dr. Baron: That's a good question. I think if you've done it for a couple months, you've done all the things you should do, get the electronics out of the room, have a regular schedule, sleep diary, at that point, that's the time you should come in and talk to somebody. And it sounds like he was working with his primary doctor as well the whole time to try to just kind of rule out the different possibilities that could be causing this. I mean, this process has probably taken a couple of years is my guess.

Mitch: We're about to enter Year 2, so here we are.

Troy: Yeah, but it's nice though hearing this, Mitch. You're right, it is frustrating on the one hand, but it's nice hearing it. You tried everything, but there are other options. And I think that's a good thing, too, to know that you can try all these things and it may just not work for you and there may be something else going on you need to address. You're doing that.

Mitch: You're not a failure. I mean, that's the thing that I kept getting in my head, where it's just like, "Am I not doing this right? This is sleep. How is this so hard? Babies can do it."

Troy:Some babies can do it.

Mitch: Some babies can do it, right?

Dr. Baron: That's funny. My patients are always like, "I bet you sleep well." And I'm like, "I struggle just like everybody else." Just the stress and bad habits. I don't always take my own advice. So it's not easy for anybody, except maybe babies.

Mitch: Sure.

Scot: Troy's a new dad, so I think he's going to argue with us on that one.

Troy:I would tend to disagree. But anyway, that's another discussion.

Scot:That's another podcast. Well, Mitch, thank you very much as always for sharing your experience. Your health journey has been interesting and it's been great to talk about. As we've talked about on this podcast, talking about it is how we help each other maybe find a path to better health, especially when something like the Core Four isn't working, and you've been honest about it, and you've given it the true shot that it deserves. Sometimes health is complicated.

Dr. Baron, thank you very much for being part of the podcast. And listeners, thank you very much for listening, and thank you for caring about men's health.

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