Sleep, Mitochondria, and Energy Balance With Dr. Lisa Portera

Dr. Kelechi Uduhiri: Sleep occupies around one third of our lives, but is often overshadowed in importance by other modifiable lifestyle factors that feel more directly under our control, such as exercise and nutrition. But sleep is critically important to daily function as well as long-term health, in part due to its impact on mitochondrial function. How does sleep impact the energy balance in the body? And how do disruptions in sleep lead to some of the most common complaints we see in our offices like fatigue, brain fog, and even chronic pain? Dr. Lisa Portera: Of all the lifestyle factors, they're all very, very important. But I really put sleep at the top of the list because when we don't sleep, we are very poor at consistency in all the others. Dr. Kelechi Uduhiri: I am IFM Director of Medical Education, Dr. Kelechi Uduhiri. And on this episode of Pathways to Wellbeing, we welcome Dr. Lisa Portera to discuss the connection between sleep and mitochondrial function, how energy balance in the body affects our daily lives, and what we can do to improve our sleep, our mitochondrial function, and overall wellbeing. Welcome to the show, Dr. Portera. Dr. Lisa Portera: Thank you so much, Kelechi. I'm so happy to be here. Dr. Kelechi Uduhiri: We are so happy to have you. It's so great to see you. And thank you for joining us today on this podcast. So let us start by talking a bit about your background. We know that you're an expert in energy medicine and that you teach about several topics including sleep and chronic pain in our Bioenergetics Module. How did you become interested in this area? Dr. Lisa Portera: Well, my background originally is a Doctor of Chiropractic and I always had a very strong love for the brain and the nervous system, and it was just a very big part of everything that I worked with. And so understanding that and then the gut-brain connections and the mitochondrial connections, it just started to unfold over the years. And also recognizing, you mentioned chronic pain and sleep and our chronic pain patients really struggle with sleep. So I needed to dig deeper and really understand aspects of how we could not only impact chronic pain patterns and very challenging chronic pain cases, but also help patients understand how to tether those connection points with sleep, find some success in their sleep, in their pain modulation, and be able to tether that together. And so much of that is rooted in mitochondrial function. Dr. Kelechi Uduhiri: Absolutely. And it's almost like a little known secret, and I'm so glad that we are going to tie sleep with mitochondria today, right? Why is sleep so critical for proper mitochondrial function? What's the connection there? Dr. Lisa Portera: Yeah, there's a number of connections, and we go into a lot of detail on this in the actual Bioenergetics Module, the Advanced Practice Module. So I would just want to definitely encourage our listeners to attend so you can get that granular information that's rooted in the science. But if we sort of take that 30,000 foot view, what we need to understand is that our mitochondria are reading what's happening all day long in terms of our use of our energy. What's our energy bank? What are the deposits we're making and what are the withdrawals that we're making? How is energy moving through our body? That definitely impacts our circadian function and that impacts our sleep. So there's a lot of points of connection. Our circadian rhythm, our circadian clocks, which are definitely impacted by oxidative stress and therefore mitochondrial function. Our metabolic function plays a gigantic role in our sleep and our sleep recovery and risks relative to poor sleep. So when we think about it at the metabolic level, such as blood sugar, insulin regulation and so forth, but we want to take it to that more granular level of the metabolism that's happening there inside the mitochondria, in our ATP production, in our oxidative phosphorylation, all of the things that we do with our sleep and create a healthier sleep cycle will impact our mitochondria at the biochemical and cellular level. Dr. Kelechi Uduhiri: Thank you so much for sharing that. And something that you said just sort of like... Well, let's not get too far ahead of ourselves. Let's talk about the mitochondria itself. Explain exactly what is the mitochondria. Then I'm going to come back to my next question. Dr. Lisa Portera: Well, it's so interesting because we've all learned in our high school biology the mitochondria is the powerhouse of the cell. It's where we make our energy. It's where ATP is produced inside the electron transport chain, inside the inner membrane of the mitochondria. And all of that is very true. It's important science to know, but what we're learning is the emerging science that's coming out now that we really understand that mitochondria are so much more. They are that and more because it's not either or, right? And it's the fact that we now understand our mitochondria as signaling systems, that they're like antenna that are reading what's happening in our physiology in all systems. Through the systems biology lens, I think gives us one of the most beautiful ways to imagine and also understand how mitochondria are central to the communication between all systems. So they're reading what's happening in each system. They're reading our levels of oxidative stress and inflammation, and when we have imbalances in various systems, it's impacting our mitochondria. So they're generators of our energy, they're cell signals, and they're very active and very alive on an energetic level. So we want to consider that also from the bioenergetics aspect of it, that we are electric beings, right? We are beings of energy and we need to protect that energy, respect that energy. I think that sleep is a really important aspect of that that sometimes gets lost in the mix, as you mentioned at the opening of this. It's a lot easier to focus on other things and forget about sleep because we have habits that we've gotten away with in certain phases of our life that can really take us down a different path of thinking, "Oh, I can get away without having sleep." Dr. Kelechi Uduhiri: I know. Ooh, so much to unpack there and we're going to come to habits in a second, but mitochondria are signaling systems, mitochondria, they're generators of energy, right? And I've heard that even mitochondria is like the original chlorophyll, right? Something like that. Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: And that is why it's so good to go out first thing in the morning and get that sun, right? Because of that... To reset our circadian rhythm and our clocks, right? So let's dive in a little deeper because that was a lot of good nuggets right there because we just say, "Oh, yeah, mitochondria, that's where we make ATP." But it's so much more than that. Let's connect it a bit more to circadian rhythm and let's tie it into sleep. Dr. Lisa Portera: Great. Okay. So there's something in our brain called our suprachiasmatic nucleus that reads the light in the morning and sets the tone for our light dark cycles and also sets the tone for our cortisol responses and our melatonin responses. So this is where I hope we can really connect some dots for our listeners today. And we really work hard to do that also in the module, the Bioenergetics Module, because sleep is more than just what happens before you go to sleep at night. It's really about how we start our day and what occurs throughout the day. So to your point, we need to get that early morning light. We need to set the circadian clock, and that is absolutely critically important. And for patients and those listening that we're going to be moving into daylight savings time here pretty soon, it's already September. So how do we make those changes and adjust for that? And oftentimes we can be using what I like to call happy lights in the house and still exposing ourselves. We have to build these habits. They stimulate the brain in such a way that light stimulates the brain in such a manner that it actually does set the circadian rhythm for the day, but also the tone in which we're going to develop enough sleep pressure and enough melatonin to be able to prepare our bodies and our body's rhythm for sleep. This also ties into vagal tone and nervous system regulation. So these are all aspects that interplay with our sleep and our circadian rhythm. Dr. Kelechi Uduhiri: So what I'm hearing is what we're doing first thing in the morning, what we're doing during the day, it's already going to impact. And how much sun we're getting, it's already going to impact how good the sleep is going to be later on. Dr. Lisa Portera: Yes, there is the morning rhythm that's critical. And then there's the things that we do or don't do- Dr. Kelechi Uduhiri: During the day. Dr. Lisa Portera: ... during the day that start to impact it. And we've talked a lot about nutrition in the Bioenergetics Module, and this is where having protein in the morning, making sure that you're eating, particularly if you have hypoglycemic tendencies or maybe you're fasting or doing intermittent fasting, but we have to make sure that even when those situations are in play for our patients that we are working with stabilizing blood sugar and insulin regulation because those impact the circadian rhythm as well. So nutrient density is very important and stress modulation is a very, very big factor. Dr. Kelechi Uduhiri: Right. I think it's so important to stress that because oftentimes we think it's just the hour before you go to sleep, right? That's what we tell people a lot of the times, that's what they hear a lot, the hour before you go to sleep or the two hours before you go to sleep, do this, do this, don't do this. But what you're saying, what I'm hearing is there's a lot that we are doing or not doing during the day that also impacts how we sleep. That is so important. Dr. Lisa Portera: Absolutely. Dr. Kelechi Uduhiri: Yeah. Dr. Lisa Portera: Our metabolic regulation, our circadian rhythm, our stress response and our metabolic flexibility, but also our autonomic flexibility and our circadian rhythm, all three of those components impact our sleep. And those are things that we have to start becoming more aware of, communicating more clearly to our patients and having dialogue and personalizing their care in a way that allows us to really help them understand what are the steps you as an individual, not the influencer on TikTok, not the latest and greatest supplement or whatever it is. We're always looking for a silver bullet. We're humans. We want the quick fix. But that's part of the problem, not part of the solution. And while certain nutrients can be very helpful, they need to be targeted in the right way at the right time of day and what we're really after. It can't just be something that happens in those two hours before sleep. So to your point, sleep hygiene tools are very important and that habit is a key aspect of part of our sleep success, but it's not the whole story. We have to start in the morning and be aware throughout the day. Dr. Kelechi Uduhiri: It is definitely not the whole story. And I think that's a really good nugget from today's session is there's a lot that we need to inquire from our patients as to how their day, what is their lived daily experience so we can support them in making those behavioral changes. Now you mentioned a really interesting word earlier, autonomic flexibility. Can you elaborate more as to what you mean by that and what it means for our patients? Dr. Lisa Portera: Well, what it really means is, and without getting too technical here and not having a slide to show everybody, I'll do my best to imagine this, right? In our minds. Our vagal tone, our vagal responses, our sympathetic dominance, parasympathetic responses really play a role in our mitochondrial function. But in our circadian rhythm, there's a very tight relationship to that. So when we are very stressed or we're out of rhythm in our circadian function, if our circadian clocks are out of balance, that is actually impacting our ability to be flexible in our responses to stress. As we have less of a threshold because our stress patterns are higher and more persistent and there are what I like to call not enough stress buffers throughout the day, that is having an impact, right? On our cortisol levels, on our blood sugar levels, on our insulin responses. All of those things are signaling a pattern to our sleep cycle. If our cortisol is staying elevated, we're not going to have that continual decline that should happen closer to dusk and dark. Did we get enough melatonin lift at the beginning of the day to actually carry it throughout so we're ready and our melatonin store is where it should be at the point before we go to sleep at night? So this dynamic is very important and underneath it is what we're doing in our day, being aware of our stress. What is our movement like? Are we exercising? Are we taking breaks? Are we breathing? How are we setting our autonomic tone? How fast do we recover from the stress? How fast do our mitochondria recover from activity or stressors? Those are what I mean by the autonomic flexibility and the mitochondrial flexibility. Dr. Kelechi Uduhiri: Because again, mitochondria are not just generators of energy, they're cell signals. They're signaling the level of stress in our body all day long, right? Dr. Lisa Portera: Yes, yes. Dr. Kelechi Uduhiri: And as you were talking, I was thinking of shift workers and how their sleep cycle is kind of off. And could what you just shared, this autonomic instability or flexibility, how does that impact shift workers? Dr. Lisa Portera: It's exactly what we're talking about in terms of the challenges with shift workers because their circadian clocks become disrupted. So their suprachiasmatic nucleus that we talked about earlier doesn't get the stimulus in the morning that it should, so their circadian rhythm is out of balance. Oftentimes their cortisol and their melatonin balances are flipped, can be reversed, or at the very least disrupted. And all of that impacts our sleep capacity. Now, what we see in the shift workers is the demonstration of that in their health risks. They have some of the highest rates of cardiovascular disease, cardiovascular events, diabetes. There's some things around pain stats also that show up and cardiovascular events. Oh, cancer rates too, excuse me. And so we see the impact of poor sleep and the disruption of the circadian rhythm and how that impacts our sleep cycle over time. And I think it's really important for people to start to understand it's not a sentence. We're not telling you there's nothing that you can do about it, but we are saying it's really important to care for our patients that are under that type of duress and stress in a different way that we would deal with the patients and address them that have normal light, dark cycles. Dr. Kelechi Uduhiri: And I think we should really elaborate on that because doctors, nurses, healthcare professionals, construction workers, there are millions of people who are shift workers. What are some of the tools or pearls that you can share with us today to help those people who are listening who A, are either shift workers themselves or support shift workers? What can we do to support them? Dr. Lisa Portera: Such a good question. It's very individual to the person, of course, because we don't know what exactly is happening, but we should be investigating what happens in their world when they are awake, when they get home. Do they have to care for a family? What is their sleep cycle? So let's firstly identify that. What does your sleep cycle look like? How can we optimize that? How can we address and support your stress level during the hours when you are awake and how can we help you move into a deeper state of sleep when you do get a chance to rest? So we want to, again, support the cortisol levels. We want to help them modulate that. We want to help... Those are great patients for being able to use autonomic nervous system regulation techniques. Very, very important for them. So that might be everything from biofeedback to neurofeedback, which Dr. Haase and Dr. Hedaya speak quite a bit about neurofeedback. It's a really excellent tool, particularly for patients who get really stuck when they've had a lot of disruption. It really resets the brain beautifully. We also can give them tools around breath work. We can give them mindfulness tools so that they really have to make that effort during those hours when they are awake and are at work as well to be able to modulate their stress. So when they do have the opportunity to sleep, they move into a more restful state and they can move into those deeper patterns of sleep. So they get that deeper sleep, they get the REM sleep, and they can have restorative sleep while they do sleep. Dr. Kelechi Uduhiri: Yeah. And I hope those who are listening today understand that it's really a challenge, right? And having these tools and having these recommendations is so helpful and truly a game changer, if it's not for you who's a shift worker, for your patients who are shift workers, because it is so different and it's so hard. And for all those risk factors you mentioned earlier, that's why I think we need to really give this population those tips. So thank you for sharing all that. Dr. Lisa Portera: Yes, absolutely. Dr. Kelechi Uduhiri: You talked about nutrition and how did you put it? Nutrients in the right time of the day also impact sleep. Can you elaborate on that piece? Because I think there's a lot of misinformation out there, right? On nutrition and we are here to set it right. Share a bit more on that. Dr. Lisa Portera: Okay. The challenge is on because we could have a podcast just about that, right? Dr. Kelechi Uduhiri: Right.Yes, we could. Maybe next time. Dr. Lisa Portera: Okay. I'm up for that. Well, I would say what are some of the pearls we want to have our listeners take away? I would say what's most important is to understand that your patients that are challenged with glycemic control and insulin resistance, insulin imbalances, that is going to impact their sleep cycle. So first of all, having a conversation with our patients and helping to identify that for them and tethering these pieces together helps them understand more what I'm doing throughout the day is setting me up. We have to set people up for success, for sleep success, right? And to be able to understand that keeping your blood sugar stable, making sure you have enough protein, fats, and carbs that are channeling into healthy carbs, using the mitochondrial food plan is an excellent approach. You don't have to be fully going ketogenic. You can use the tool... I want to just really emphasize this, the nutritional balance and density in the (IFM's) Mitochondrial Food Plan is so rich and so targeted towards supporting our mitochondria and our blood sugar regulation that it's just a beautiful place to start. And then if you have patients who really do need to go to producing more ketones for varieties of reasons, which we go into great depth in the Bioenergetics Module about those patient types, then you can move them into those steps. But we would never take a patient who is really, really struggling with their blood sugar regulation, move them straight away into ketosis unless there was a neurological component or reason for that to move them through more quickly. We have to help people modify and take the steps up toward blood sugar regulation. So that's key. Being able to make sure that they have the nutrients that are really supportive of their mitochondrial function, the B vitamins, the magnesium, the healthy fats, the phospholipids, the acetyl-carnitine, the NAC, formulas that have nice combinations of those are really important for patients. However, that said, it's not a replacement for diet. It's a tool, it's a bridge. Those nutraceuticals are a bridge while the patient's really learning how to fuel themselves more appropriately. If they have deficiencies, great tool along the way. If they have continued insufficiencies, very important to support that, but it's not a replacement, and I'm very clear with my patients about that. This is a bridge, this is a tool. This helps uplift you and get you there faster, but you have to sustain it at some point through your dietary changes, through your blood sugar regulation and through movement because we always want to have some movement after a meal. Even if it's 15 or 20 minutes, the science is so strong. Take a 20-minute walk after each meal. It doesn't have to be a run. It doesn't have to be going to the gym, and we are already regulating. We're moving those GLUT4s to the surface of the cell. We're letting that insulin channel open. We're balancing the communication and those micronutrients. We're transferring that information into the nucleus of the cell. We're fueling the mitochondria, but if we overexercise, we are depleting the nutrient density, that's one thing, and we're really straining the mitochondria, and that impacts our sleep as well. Dr. Kelechi Uduhiri: Wow, that's so awesome because I think that sometimes we lose track of the simple things we can do during the day. The nutrition is so important because like you said earlier, there's the insulin resistance, there's the blood sugar control. That is so important to help manage, right? And support and resolve because that impacts sleep. So that's really good I took away from that. We're going to come to exercise in a second. Do you recommend or refer your patients to other nutritionists or dieticians to help them with this nutrition piece so that they can... As they're trying to improve their sleep, how do you work with teams or other professionals? Dr. Lisa Portera: Great question. I will have a conversation with the patient myself first and I'll see how open they are to it and I'll ask them if they'd like to try on their own, but I make sure that there's a follow-up appointment pretty shortly after that so we can track, even if it's a phone appointment. So we want to be able to support people again in feeling empowered and successful, not, oh, I tried that it didn't work, I couldn't do it. If I have patients who I feel that are really going to struggle with it, I want to put a net underneath them and I want to build a team around them. So definitely reaching out and many times have had various scenarios where I'm either referring to or there's someone in my clinic, however the situation unfolds, but have a nutritionist on board that can really dial it in specifically and create markers of success for the patient so they can see, wow, I was able to do this. I'm starting to notice this impact on my sleep. We see a direct relationship between the improved function of our mitochondria on our sleep cycles. We go through a deeper, more restorative sleep when our mitochondria are optimized. Dr. Kelechi Uduhiri: So nutrition helps with that. It's important to work with the nutritionist if people are struggling with doing it on their own. Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: And then you also mentioned exercise. Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: Tell me a little bit more about, because there's all this myths out there. If you exercise too close to bed, it's not good for you, it messes up your sleep. What is the truth about exercise and sleep and how close or far away from sleep we should exercise? Dr. Lisa Portera: Yes. So let's talk about your specific question, which is how close or far away? The science really points to not doing exercise that is very activating three to four hours prior to sleep, so a hard workout. Now this can be challenging for some patients because of their work schedule, their life schedule. Maybe that's the only time that they can do it, but we can help modify different things that they do during the day so they have more activity, they can track their activity. If they have some wearables, they can track from that perspective too and get a better sense of what's really going on for that individual. Now, movement is really important, but what we're seeing is movement throughout the day, and then there's lots of data on "exercise snacks" and just making sure that you're moving. Sitting is the new smoking, that's true. Too much sitting, and then all of a sudden we blast our body with exercise before bed. We're going to feel that. We're going to have an elevation in cortisol, we're going to have catecholamine elevations, and now our brain is activated, right? And that's going to impact our sleep. So I would say three to four hours prior to bedtime, it shouldn't be too strenuous. Now, a lovely gentle walk after dinner where maybe you're listening to some music, not a really super activating podcast that's going to get you all fired up. That's not the best idea either, but really taking the time to look at nature, appreciate what you're seeing, let your eyes take in the color, the textures. Your brain is reading all of that. If you're out at dusk, your brain is reading that. I'm noticing, your brain's saying, "I'm noticing it's time to start getting ready for sleep." And if we've set the tone properly in the morning, we've stabilized our blood sugar throughout the day, and we have made sure that we have some stress buffers in place, our circadian rhythm is improving. It's never going to be perfect because life happens, but that we're continuing to have consistency, then we can move into a greater state of sleep. Some patients just do better with morning exercise. They feel like they have the energy for it. I find that works really well for a lot of people. Some people need a break in the middle of their workday and they go to the gym and burn off all the stress from the morning. Have at it, right? But just don't do it too closely to bed if it's very activating. Dr. Kelechi Uduhiri: Great. So thank you for setting us straight on that one. Now, what exactly is exercise doing to our mitochondria? Is it cleansing? Is it detoxifying? What is the impact of exercise on the mitochondria? Dr. Lisa Portera: It's actually stimulating our mitochondria in a way to produce more what we call mitochondrial biogenesis and improving the actual number of mitochondria in our body. We're turning on certain pathways in the body, our sirtuins, we're creating more efficiency within our mitochondrial ATP production. And yes, we're going to have some cleanup going on too, but we actually do quite a bit of cleanup during sleep. Dr. Kelechi Uduhiri: Absolutely. Dr. Lisa Portera: I just want to note that Monique Class does a great presentation on exercise and mitochondria in our module too, so we get a little more granular there. Dr. Kelechi Uduhiri: Absolutely. Yeah, because I think we exercise and I think it's so important to know that it is really getting to that very cellular level essentially, right? Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: And the fact that it's increasing the number of mitochondria is also helpful, right? So it's giving us energy. That's why we have that runners or after you exercise, you have this little bit of a high to you, right? Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: So yeah, thank you. I really believe that exercise is important in so many ways, and it does help us also improve sleep because again, it's working at the mitochondrial level. Exactly. And we know that's connected to the quality of sleep that we're getting. Dr. Lisa Portera: Yes. And we see a lot in the data around high intensity interval training and being able to shift how we're exercising so that we don't have to do it for these long periods of time. A lot of times patients will say, "I don't have time to exercise." Well, it doesn't have to be something where you have to drive your car, go to the gym, work out for an hour, drive another half an hour back. Now you had two hours out of your day. We need to make it practical. They can do things, and Monique talks about these options, you can step outside your desk and do some high intensity movement. You can do some squats, you can do some things that actually will activate your musculature, your mitochondria in a very efficient way. It's the consistency yet again, and it's really understanding what those options are. So I definitely invite you to tune in and hear, get the details on that from the module. Dr. Kelechi Uduhiri: And when we're asking patients to move and exercise 10, 15 minutes after a meal, what is actually happening in the body when they're doing that? Dr. Lisa Portera: Oh, a lot of things are happening. We're regulating... I think one of the most powerful things that's happening is we're regulating our autonomic nervous system yet again. We're sending signals of healing to the body, but at the cellular level, we're moving and transporting those GLUT4 molecules to the membranes of our cells and opening the channels to allow the glucose to enter so we don't have this insulin resistance going on and changing the morphology of our cell membranes and our receptors. So it really helps to modulate our blood sugar and our insulin resistance in a very big way. And that has a very massive impact on our sleep. Dr. Kelechi Uduhiri: Right. Because you mentioned that earlier, right? It's important to address insulin resistance, glucose regulation, and that also impacts how we sleep. So it's all kind of connected. So what we're doing here is really helping people connect the dots. Dr. Lisa Portera: Yes. And that's what we have to help our patients do. Dr. Kelechi Uduhiri: Exactly. Exactly. So that's amazing. We talked a bit about wearables. Well, you alluded to it earlier and it's such a craze now, right? There's an Oura ring, there's this, there's that, there's that, right? And I stopped checking my sleep quality because it was just consistently bad. I'm just going to admit it. And I just got so frustrated. And my question to you is, are they really accurate? Because there's a lot of context that the Oura or the whatever wearable that you're tracking your sleep does not have. Think of that mom or dad who's taking care of a newborn, right? And has to get up in the middle of the night to take care of the baby. The device does not have any context to understand that's why the sleep is bad. So is there something that... How do we help people understand that it's not all about the wearable or is it about the wearable and how accurate are they? Dr. Lisa Portera: Yeah, it's such a great question and I think the answer is going to continue to unfold as I point to my Oura ring. Dr. Kelechi Uduhiri: I [inaudible] this morning, Dr. Portera. Dr. Lisa Portera: I'll be honest, it wasn't the greatest night's sleep that I've had. And I woke up this morning thinking, "Well, isn't this ironic? I'm going to go and speak about sleep." But it's also real. So let's just get real about this. This is so important. I love this question. Thank you for this question. So I see two parts to this. So the first one is, are they accurate? I think there is accuracy here, but when we look at... I know people, clinicians who wear a WHOOP and they wear a WHOOP device, they wear an Oura Ring, they have an Apple Watch, they have all these things and then they're cross comparing. And there is variation. So it's not always one to one, but I think the power and the value in the wearables is being able to track patterns and listen to the feedback, right? That it's giving you to ask yourself a deeper question. How am I caring for myself or not? So if we take that back to circadian balance, we take that back to autonomic balance, we take that back to saying, if I use this device as a tool to help me improve my self-care, not my self-condemnation, if I have a bad night's sleep, if I didn't get my 10,000 steps, I'm blowing it, it's not working, my program's not working, all the things that our brain loves to do with the information. The value in these isn't in a one-day result. And that is so important for our patients to understand and for us to communicate to them because they can be very hard on themselves and that can move them down a pattern that's very honestly destructive in a lot of ways. But what we want to do is help them understand, look at the trend over seven to 14 days and how well are you caring for yourself? Where are the areas that you can empower yourself to improve? Not beat yourself up about it, but lose it as well. Isn't this interesting information? Be curious instead of critical and really learn something from it. And there are times when I've taken my ring off because I'm traveling and I'm teaching and I'm like, forget it. I don't even want to know because I know it's not going to be. Dr. Kelechi Uduhiri: I intuitively know it's not happening, right? Yeah. Dr. Lisa Portera: Exactly. Dr. Kelechi Uduhiri: That is such great advice and I love that because we are our own worst critics, right? Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: And I love what you said. Look at the information that it's giving you over a two-week window and just reflect and be curious and ask yourself questions. What is this telling me about my self-care? What does it tell me about my sleep in general? And what questions or what things can I do? So speaking about that, what are some of the mindfulness or are there any other practices that can allow us some intentional rest during the day and that can also impact our nervous system and our sleep? What are other things we can do? Dr. Lisa Portera: Yes, that is such a powerful question. It really is about understanding to turn within and look within because... And I can tell you that I am guilty of this and I've had to learn this myself. So I'm not saying it like I have all the answers, saying we are all human and we need to come together and rally around our patients and help them understand this as well, which is if your mind moves very quickly and you are going all day and you have a job that creates a need for you to just check out in time and focus in, you can spend two, three hours sitting or on your computer and that time has gone by and you really haven't moved your body. One of the nice things about the Oura Ring is it does tell you you've been sitting too long, get up and move. Time for a movement break? Yes- Dr. Kelechi Uduhiri: Yes, almost. Dr. Lisa Portera: But to that point, from a mindfulness perspective, I really like to have patients set a timer on their phone to interrupt that pattern of persistent push because when we're in that push for long periods of time, yes, we need to focus, but we need to take breaks too. And the brain responds to that, our mitochondria respond to that, our oxygenation responds to that. We actually perform better if we take those breaks and move our bodies. Now the challenge is don't get ourselves off on some other tangent and now we're completely distracted and lost track or we won't do that again for ourselves, right? So it's a very specific tool that we use. Set a timer. It's either on your phone, it's on your computer, it's on your wearable, and allow yourself a five to 10 minute break. Move your body, hydrate, do a few movement exercises. I know some doctors who tell their patients to dance, turn on some music and dance, have some joy, deep breaths. So having that on and building that into your day is very powerful. Breathe. We don't do that very well. Breathe throughout the day. Am I holding my breath? Am I breathing shallow? Am I breathing from the chest up? That's a sign that we're in sympathetic dominance. Am I breathing more deeply from my belly? Can I stop? Also with that timer, can I set breath breaks? Deep breathing, just deep in the belly, stand up, reach your arms, open your chest, move your diaphragm, breathe, oxygenate your body, reset your nervous system. Your mitochondria will also respond very favorably to that. Those are things that help to also mitigate the cholinergic stimulus that happens when we're stressed and we're not breathing and we're sending signals of alarm to our body. So breathing, breath work, take breaks, move, guided imagery, take a break and maybe put in your headphones and do 10 minutes of guided imagery or guided breath work. Do that in the evening before bed or if you awaken at night. I do have patients who I have them put their headphones near their bed if they're really struggling. And the rule is you may not scroll and you have to have blue light glasses. So have all the setup. If you really wake up and you're struggling because you're awake for a couple of hours of the night, have yourself ready to go and you plug in some great apps that are out there, Calm, there's other apps, and you can just plug right into certain hertz, certain frequencies that put the brain and the body back into a state of coherence and you're back to sleep in no time. So there's ways in which you can really modulate throughout the day, prepare right before bed. And if you do awaken, there's some things that you can do for certain patients. Some respond very well to that, maybe not everyone, but we want to definitely look at the mindfulness practices, looking inside the body, listening to it interoception, what is the body telling me? What is the body feeling? What is the body experiencing instead of what's going on in my head? I'm only thinking with my head. When we're really in our heads, we're not in our bodies fully, and then we know it's time to take a break and shift. Dr. Kelechi Uduhiri: And all this that you shared, again, reminds me of how we started the conversation, which is the mitochondria, they are signaling systems, right? So it's understanding what's happening. It's reading the energy that we're putting in or not putting in. Dr. Lisa Portera: That's right. Dr. Kelechi Uduhiri: And that is also setting the circadian rhythm and ultimately helps us with the quality of our sleep. Did I get that right? Dr. Lisa Portera: You got it. That's exactly right. And so really helping our patients understand these points of connection. It's not just about a one nutrient for our mitochondria fix. It's about taking action and empowering ourselves to really holding the power of, I have control over my sleep, but I have to really make some changes that maybe I've been a bit resistant to. I need some consistency. I'm not looking for perfection, but I'm looking for consistency. Dr. Kelechi Uduhiri: Yes. And not being critical of ourselves either when we're getting all that data. It's about stepping back and what is it telling me that I need to do differently? Dr. Lisa Portera: Yes, yes. Because sleep is not something that's nice to have when it happens once in a while. It's foundational. It's a requirement. Dr. Kelechi Uduhiri: It's a requirement. Dr. Lisa Portera: ... for our health, for our long being, for our mitochondrial function, for our cardiovascular health, for our cardiometabolic health, for our immune function. When we don't sleep, we actually have dramatic reductions in our natural killer cell activity. So it's the foundation. Let's embrace the fact that we have more power over it. And if we're really struggling and the patients are really struggling, let's figure out the why and really help them work through those steps. Dr. Kelechi Uduhiri: So sleep is no longer a nice to have, it's a must have. Dr. Lisa Portera: Yes. Dr. Kelechi Uduhiri: And we need to let go of that culture that we've been so ingrained in that says just power through, just push through. You don't need seven to eight hours. Is that your recommendation, seven to eight hours of sleep? Dr. Lisa Portera: Seven to eight. It's actually seven to nine for adults. And then when we look at teens, it's more like nine to 10. As we go through the younger years, it increases all the way up to infants up to 14 hours in a day. So we can see that the body requires sleep, right? For healing, for growth, for repair. When we don't have sleep, we don't repair well. And when we do sleep, we also activate our glymphatic flow, that flow of cleansing all of the metabolites from the brain, those tau proteins. We wake up foggy when we don't have good restorative sleep because we haven't had a good cleanse in our brain. That's a very big part of it as well. And we talk about that a lot in the module. Dr. Kelechi Uduhiri: And I think that is so important to remember that again, it is not a nice to have. It is not a, okay, I'll get to it. It is really a must have for healing, repair, and just prevention of disease. We need to sleep. We must sleep more. Okay. And as someone who has been working in this area for so many years, where do you see the field of sleep and mitochondrial function and energy going in the next few years? Dr. Lisa Portera: That's such a good question too. You have so many great questions today. Thank you. Dr. Kelechi Uduhiri: I'm going to have to have you come back. Dr. Lisa Portera: Well, I think we're at sort of a peak in terms of people's awareness of mitochondria. I think that there's a lot of patient and consumer desire to know more about it, to leverage our mitochondrial health. It's definitely now looked upon as essential for longevity health, most definitely. But I think what we're also starting to understand, as we talked about at the very beginning, how mitochondria are these signaling systems that are speaking to every system of the body. They are one of the main ways in which the systems biology matrix, a functional medicine matrix, right? Communicates between all the various systems. And so we're learning more about that. We're learning about how, for example, gut metabolites impact mitochondrial function, how immune function translates through the capacity of our mitochondria. So if we have poor mitochondrial function, it's going to impact our immune state. We're learning how our mitochondria, and it's really interesting because we're talking about peer review cardiology journals that are now starting to say it's more than just the mitochondria to pump the heart and have good circulation. It's that the mitochondria are essential for actually addressing our cardiovascular needs. Definitely important in our hormonal health because we make our hormones on the inner membrane of the mitochondria, our steroid hormones. So I think now what's happening is we're starting to see this pattern emerging that we're having respect for the mitochondria. It's getting some respect in its ability to really demonstrate its role in all systems and demonstrate its role in our sleep and being able to also demonstrate its role, and this is the work of Dr. Martin Picard, in our stress modulation, in how our mitochondria read our stress and then interpret it and communicate to the rest of the body in terms of how our mitochondria function, the morphology of them. So we're learning so much more now. It's like we're in this accelerated pace, and I think it's just going to continue to come together just like functional medicine has come together, these ways in which things are connected. We're really seeing that strongly from the mitochondria perspective now. Dr. Kelechi Uduhiri: Wow. So much is coming out right now and so much more for us to learn. I wish we had so much more time because you just gave me a lot of good nuggets there. But as we bring this episode to a close, Dr. Portera, what are the key takeaways you'd like functional medicine practitioners to remember regarding sleep, energy balance, and mitochondria? Dr. Lisa Portera: I have to pick a few. Dr. Kelechi Uduhiri: We've seen a lot. We went through quite a lot today. Dr. Lisa Portera: Okay. I would say first and foremost, sleep is a non-negotiable. It is absolutely fundamental. And my personal opinion, and I mean that because I have seen it so many times over the years in clinical practice, of all the lifestyle factors, they're all very, very important. But I really put sleep at the top of the list because when we don't sleep, we are very poor at consistency in all the others. It impacts our ability to have good, consistent movement. It impacts our ability to make good dietary choices. When we sleep poorly, we crave more sugar. We eat more sugar. When we drink more alcohol, we don't sleep so well. And it really impacts our stress level and our stress level is impacting our sleep. That's a bidirectional arrow, right? So getting the sleep to become more consistent and more restorative, more REM sleep, more deep sleep, getting through enough sleep cycles in a night, those are the things that we're going for. Okay? Second, your blood sugar regulation. That is partnered with your sleep so tightly. So really looking at our metabolic function through the lens of blood sugar, insulin resistance and metabolic flexibility, absolutely fundamental, super important for our mitochondria and very much entwined. So anytime we're working with a patient's metabolic flexibility, think about their sleep cycle, ask those questions. Sometimes we forget to ask enough about sleep. So I put that as number three, maybe even number one, so that we can get to what we need to address for the patient. And one thing I do want to say that we haven't mentioned yet, just really briefly is it's also important to ask patients when they go to sleep at night why they think they're waking up and help them really understand and identify that so we can build some tools for them to address those things. Maybe they do need some therapy, some psychotherapy, some cognitive behavioral therapy. Maybe we need to be referring out for certain things. Have we assessed that patient for sleep apnea? Let's make sure we've ruled those things out. But additionally, and we talk about all of that in the module as well, but one thing I think is really important is do you feel safe when you go to sleep? Was there some potential trauma earlier in life or currently? What's their level of safety? Let's discern that too. Let's remember to ask. And then I love the question is, if you were sleeping well and you had the energy that you desire, what would your life look like? How would you imagine that to be? Because if they could anchor into their why, they're much more willing to apply those consistent things that we've discussed today throughout the day. That's just so key that their why needs to be at the center of all of the recommendations that we're making around this. Dr. Kelechi Uduhiri: And that is how we get that behavior to change. Oh, my goodness, that was so good. Thank you so much for those wonderful pearls. Start with the why for the patient. What would happen? What would change if you got better sleep, more restorative sleep? And I think that's a great place for us to close. We could spend a lot more time here. Thank you so much for your time this afternoon, and I hope you say yes next time to coming back because I feel like there's so much more for us to discuss. So thank you, Lisa, for being with us. I appreciate you. Dr. Lisa Portera: Absolutely. Thank you so much. It's been an absolute pleasure. Dr. Kelechi Uduhiri: Alrighty. Thanks. Take care. Dr. Lisa Portera: Thank you. Bye-bye. Dr. Kelechi Uduhiri: Thank you for listening to the Pathways to Well-Being podcast. Click on the subscribe button so you'll never miss an episode. For more information on this topic and functional medicine, visit ifm.org. The future is functional.