In May, I sat down with author and behavioural sleep medicine specialist Dr. Jade Wu to discuss sleep and midlife. In her book Hello Sleep: The Science and Art of Overcoming Insomnia Without Medications, Dr. Wu presents an approach to healthy sleep that’s refreshingly human, genuinely hopeful, and deeply helpful. 

‍During our conversation, Dr. Wu shares about the Hello Sleep philosophy, tackles some of our most common sleep concerns, and offers practical things you can do right now to start building a stronger, healthier relationship with sleep in your second half. She also shares her journey into sleep science (It involves astronauts and military bases!). Enjoy.
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A better approach to sleep, finally 

Annie Brandner: On a road trip a few years ago, my husband and I were listening to an interview with a sleep expert whose book I had picked up. For nearly two hours, we listened to him sharing dire statistics about the cost of not getting enough sleep, and his suggestions for regaining control. 

We found ourselves tallying up all the ways we had “failed” at sleep over the years, wondering how much time we’d shaved off our lives as a result. It was so stressful! It had some fascinating information, but I could never recommend it to my friends who actually struggled with sleep! That kind of intense pressure to get it right and fix it fast would only exacerbate things for anyone who was already stressed about their sleep. 

Fast forward to last month, when I started reading your book. I was immediately struck by how different it was. It had all the fascinating information, but none of the pressure. The approach you outline in Hello Sleep feels so human, so hopeful, so compassionate. It’s such a refreshing take on sleep. The further I got in the book, the more I could feel my whole body [audibly exhaling] relax. 
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Dr. Jade Wu: Oh good! Thank you for sharing how it resonated with you. That's exactly what I was going for.

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There are countless books, products and services marketed to people in midlife, promising to fix and optimize our sleep. In your work, you’re shifting the paradigm away from sleep as a problem to solve or a process to optimize and toward approaching sleep as a friend with whom we have a relationship. Why is this shift so important? 

You know, as we enter middle age, we start to notice the aches and the pains, and we start to feel our mortality creeping up on us. So it's understandable that we’re looking for fixes or solutions, ways to manage, control, optimize or hack this thing that suddenly feels like a big project or problem. 

sleep is one of the few things in life that does not improve the harder you work on it.

I really like that people are starting to pay attention to their sleep health in midlife. Unfortunately, the way most of us tend to approach new challenges is to manage or enact control — we think if we just work harder, things will get better. And that probably works for a lot of other aspects of life, but sleep is one of the few things in life that does not improve the harder you work on it. 

Sleep is still kind of a mystery. We know a lot more about it now than we used to, but there's still so much we don't know. There’s a bit of hubris, I think, in biohacking culture, where we think, If we drink tart cherry juice, do a cold plunge, and set our room to this exact temperature, then we will have controlled all the factors that affect sleep. But there are probably a million other factors we don't know and may not be able to control.

Did you know? "Sleep hygiene is the placebo condition in many insomnia clinical trials because we know that it does not work for insomnia." (Hello Sleep page 49)

When we keep trying to control what we don't fully understand and can’t actually control, we end up adding so much more stress. And in the process, we wind up putting more distance between us and this experience we used to understand much more intuitively.

What if sleep was no longer a tug of war? What if we just dropped the rope?

So I’m asking, What if sleep was no longer a tug of war? What if we just dropped the rope? What if instead of a project that we need to manage, sleep was an intuitive thing that we trust we already know how to do? Many of us really do need to reset our relationship with sleep, giving it the nurturance it needs, and learning to step back when needed, too. 

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Dropping the rope sounds freeing, and also a bit scary. 

A lot of people have shared that this process is liberating. They're not beholden to a strict sleep regimen anymore, so they’re no longer carrying a sense of guilt or anxiety about whether they've done everything perfectly. Then lo and behold, when they no longer feel that tension and anxiety, their nervous system cools down. As they approach bedtime, their body is no longer getting the message that it’s time to gear up for a fight. And they actually sleep better. 

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What is insomnia, really? 

Hello Sleep focuses on treating insomnia. And it really expanded and clarified my understanding of the term. Can you define insomnia for us?

Sure! Insomnia is when someone has trouble falling asleep, staying asleep or they’re waking up too early. It's very much in the eye of the beholder —we don't have any clinical cut offs in terms of how many hours you're sleeping, or how many times you wake up during the night. If you feel like you're waking up a lot, or you're having trouble falling or staying asleep, then that's insomnia. 

If you feel like you're waking up a lot, or you're having trouble falling or staying asleep, then that's insomnia.

Acute insomnia is when it's short term – one or two nights or even a couple of weeks. Everybody experiences that from time to time. I had that last night, for example. I had trouble falling asleep for a couple of hours, so I got up and did something else. Totally normal. 

Chronic insomnia is when that has been going on for, according to the clinical threshold, for at least three months. Though most people who come see me have had it for years or decades. 

For it to be considered clinically diagnosable insomnia disorder, there has to be the element of daytime impairment or distress. It makes you feel tired, you feel physically ill, or your mood drops. It affects your ability to live life to the fullest. 

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In the book, you walk readers through the steps of the Hello Sleep program you run in your clinic to treat insomnia. Can you give us a glimpse of how that works? 

Sure! Hello Sleep is an approximately eight week cognitive behavioral program, based on Cognitive Behavioural Therapy for Insomnia (CBTI), which is the first line gold standard treatment for insomnia disorder. 

CBTI is like physical therapy, but for your sleep. Physical therapy is tailored to the individual person. You start out by understanding the issue: is your ankle broken? If so, which way is it broken? With CBTI, we ask: Do you have a strained relationship with sleep? If so, in what way?

We get a good understanding of how sleep is going, then we apply some tried and true, evidence-based strategies to shift how we act and think around sleep, so we can reset the physiology of sleep. 

We also look at changing the anxieties and pressures we put on ourselves about sleep. Can we loosen up some of those catastrophic beliefs, can we loosen up some of those rigid expectations? And if we do, how does that affect our sleep quality? 

Essentially, it's a big reset button for our relationship with sleep, with very concrete tools. Once you're done with the program, you've got tools you can use for a lifetime to maintain your good relationship sleep, even as things change with your health, your environment or your lifestyle. 
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Midlife sleep changes

Let’s talk about sleep in midlife. You write that it’s important to be open to a healthy relationship with sleep in midlife that looks different than it did earlier in life. Many would say their sleep in midlife isn’t just different, it’s worse - and that there’s less of it. That kind of “different” can feel frustrating and like a kind of failure when you feel like you’ve been trying everything. 

Can you speak to these changes to our sleep, and that sense of frustration and uncertainty?

Yes! This is such a good question, because midlife is definitely a flash point for sleep. It's perhaps the first time someone is realizing, Oh, my sleep is different, and it's been different for a while now; this isn’t just a once in a while thing — whether it’s insomnia or sleep apnea, or other sleep issues. 

Change is normal

The first thing I’d say is that there are a lot of natural, normal, healthy changes with sleep as we enter midlife. It can be helpful to remember that we've actually experienced tons of sleep changes throughout our lives. 

When we’re first born, we sleep up to 18 hours; as babies, we sleep all around the clock. As children, we consolidate our sleep to nighttime. As teenagers, we're typically night owls; we just can't fall asleep very early in the evening, and we love to sleep in.

our sleep actually changes a lot at every developmental stage, and midlife is no different.

So, our sleep actually changes a lot at every developmental stage, and midlife is no different. And there are a few potential reasons for the changes we see in midlife. 

We need less recovery 

As we get older, we need different things from our body than we used to. As kids, we’re growing our brains and our bodies. In our 20s, we're still growing our brains, and our reproductive systems are working hard. In our 30s, we’re coming up in the world, working, and maybe we're chasing after kids. Once we reach our 40s and 50s, we're no longer putting the same wear and tear on our bodies we did when we were younger. And since sleep is basically recovery from what happened during the day, when we have less to recover from, we need less sleep — and specifically less deep sleep. 

We’re playing a new role 

In midlife, we also tend to have more awakenings during the night. Again, all through our early adulthood, we have a dozen awakenings through the night, most of which we don't remember. But as we get older, we tend to remember them better, and they tend to lengthen out – this is partly because we need to use the bathroom more, and partly because of — well, I'll get to menopause in a moment. 

But my theory is that evolutionarily speaking, if the young folks were going hunting, carrying babies and tending children during the day, then we middle aged people — who, in the caveman days, were basically on our death bed—we played our part in the tribe by being more alert and awake at night, in case there's a tiger in the bush, so that the younger people can get their deep sleep so they can go hunting and take care of the babies during the day. 
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Midlife sleep flash points

On top of that sort of normal progression, there are also three common points in midlife where people start to have sleep problems: 
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Caregiving: Whether it's having kids or older parents who need care – or both —caregivers are constantly on, going going going all day. The message their body is getting is that there must be sabre tooth tigers lurking everywhere; otherwise, why wouldn't they be slowing down during the day? 

Perimenopause and Menopause: During perimenopause and menopause, the instability of the amounts of hormones in the brain and in the body can increase anxiety and irritability, increase body temperature, and even more nuanced things. With less estrogen, there's less muscle tone, so we are more likely to have the muscles in our airway collapse during sleep, which can lead to snoring and apnea. We experience more urination at night, more awakenings. 

Retirement: The third flash point that I often see, especially for men, is retirement. When people retire, they often go from a mentally stimulated, socially connected, physically active life to one of sedentariness and possibly stagnation. One moment they have a strong sense of identity, and then that drops off a cliff. That's a sudden change that really can wreak havoc on people's mood and physiology. So it’s no surprise that a lot of people suddenly start to have sleep problems after retirement. 
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What you can do today

Let’s say a client from this age group comes to your clinic. Maybe they’re starting the Hello Sleep program or you’re just exploring what’s going on. When they walk out of your office on that first day —are there things you recommend they start doing right off the bat as they begin this journey? Things our readers could start doing today?

Yes. What I would probably say to everybody, regardless of what kind of sleep issues they're showing up with, is: 

1. Listen to your body, and 
2. Be open to the idea of change. 

Once you can do those things, you can start getting to know what's normal aging and normal changes in your sleep and what's actually something that you need to address. You could need actual medical intervention; if you have sleep apnea or some sort of circadian rhythm disorder, something needs to be done about that. 

You can only realize what's wrong, though, if you can accept that what's right and normal today might be different than it used to be. It might look and feel different than it used to. So that's a good place to start. 

Light, movement and connection

And another thing I’d say is that people often underestimate how important it is to do things during the day to procure better sleep at night. We often focus on what we do at bedtime and what we do in the middle of the night. But more than half of the issue – and more than half the solution — is what you do during the day. Being physically active, getting outdoors into the actual sunlight, being socially connected, these are probably the most important things you can do for your sleep health.

people often underestimate how important it is to do things during the day to procure better sleep at night.

So light, movement and connection during the day. I heard it’s especially valuable to get out into the morning light without sunglasses so our eyes get that direct light - is that true? 

Yes, that’s important. We humans are day animals, so a big part of how our whole system functions is our brain knowing when it's daytime and when it's nighttime. If the brain is very clear on the time of day it is and has a really steady 24 hour clock, then all of the things in our bodies, including our sleep cycle, our metabolism, our body temperature, our cortisol, our hormones, all these things then run in sync and run on time. So the strongest signal you can send to your brain about what time it is is the amount of light entering your eyes. That's why daytime light exposure, especially in the morning hours, is just a super powerful thing you can do for your overall health, including your nighttime sleep. 

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Watching the clock 

One pain point for many people in midlife is watching the hours tick by on the clock through the night. You say that tending to our relationship with sleep includes tending to our relationship with wakefulness. What would you say to people who are really frustrated about being awake at night? 

The first thing to know is that waking up during the night, in and of itself, is not a bad thing at all. It is perfectly healthy and normal. We all wake up a dozen or more times a night. We don't remember most of those, but it's built into healthy sleep. 

We all wake up a dozen or more times a night. We don't remember most of those, but it's built into healthy sleep.

Despite all the talk about a solid 8 hours, sleep is not like turning out a light and then we're out for X number of hours and then we turn back on. We actually go through a very dynamic and active process in our bodies and our brains, through different cycles and stages of sleep. I like to visualize a whale that dives down to eat krill or whatever they eat, they come back up, they spout, then they go down again; it's more that kind of up and down process. 

First and second sleep

The human brain actually evolved to sleep in two chunks during the night, which is called biphasic sleep. Before industrialization, people would go to bed fairly early, sleep for a few hours, get up for a good two to three hours — rising bread, visiting neighbors, doing chores — and then go back for their second sleep. That was the normal way to do it. 

Now in our modern life, we've come to expect that we should sleep for one continuous block and ideally have no awareness of what happened during the night. But that's not actually how our biology works, and it's an unnecessary, sometimes stressful expectation. So, if someone is retired and doesn’t have strict obligations on their time, if they end up doing biphasic sleep, that’s perfectly okay. 
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So waking up in the night is not bad. But doesn’t it leave you tired in the morning?

It's usually when people are anxious or frustrated about being awake that they get into trouble. For one, they end up being awake longer because anxiety and frustration are not very relaxing, sleepy experiences. Then the next day, when they feel really crappy when they wake up, they tend to blame it on the fact that they woke up during the night, where it's more likely the fact that they spent two hours tossing and turning being frustrated, bored and anxious that made them feel that way. 

Did you know? “The act of trying to sleep, like flailing in quicksand, is probably the worst thing you can do in an insomnia moment.” - Jade Wu

If I made you lie down right now in the middle of the day for two or three hours, and I said, “You're not allowed to do anything interesting or productive or fun. You just have to lie there and be frustratedly trying to do something - sleep - that’s not going to happen.” You're likely going to feel exhausted and terrible afterwards, right?

And really frustrated.

Absolutely. Now imagine doing that night after night after night, and then feeling guilty about it, or feeling like a failure, or worrying that it's going to give you dementia! I mean, of course you're going to feel more tired and irritated during the day. 

Now, imagine if you spent that same amount of time awake during the night, but instead of lying there feeling frustrated, you did something enjoyable — you read a book that was interesting, or you did a puzzle that you had been wanting to do, or you doodled, or journaled. Even if you spent the exact same amount of time awake, you’d likely end up feeling better rested and more ready to face the day in the morning — and I bet you’d be less likely to have insomnia again in the future. 

When we stop putting pressure on ourselves to stay asleep with no awakenings or to get back to sleep really quickly when we do wake – if we let sleep come to us instead of trying to hunt it down, then we often end up sleeping better and end up feeling better.

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Sleep aids and medications

Talk to me about melatonin, sleep aids and medications. I know many people rely on them. When we’re tired and wired, it can be so tempting to just take a pill and hope it works. 

Let me say first that I am not anti-medication. There is very much a place for sleep medication and sleep aids, and mostly it's for short term use. So if someone is going through a really stressful time where they just don't have the wherewithal to consider behavioural interventions for their sleep — like if they're going through a divorce or they just moved or they're jet lagged, then by all means, use the tools that you have to get over this hump. 

There is very much a place for sleep medication and sleep aids, and mostly it's for short term use.

But sleep medications don’t generally address the underlying issues of sleep problems. So if it’s the only tool you’re using, it can actually make the problem worse in the long run, taking away your own confidence about your sleep. 

I won’t go into too much detail, but if people want to get off of sleep medications, it's very possible to do that. I recommend starting with Cognitive Behavioural Therapy for Insomnia while holding their sleep medications steady— not changing too many variables at once. Then, once they feel good and confident about their sleep, they can gradually taper off of it. I’d say that's the most sustainable way to come off of sleep medications, if someone wants to do so. 

Misunderstanding melatonin

Now melatonin is special as it’s a particularly misunderstood sleep aid. Melatonin is a time-keeping hormone that we already produce in our brains. It ramps up in the evening, stays high at night and goes away in the morning hours. 

Because it’s a time keeping hormone, it should be used for shifting our circadian clock. It can be useful for people with chronic jet lag, those who do shift work or who have delayed sleep phases. But it’s not really helpful for the run of the mill insomnia. 

In fact, most people are taking it wrong, taking too high a dose too late in the evening. This can backfire because it lingers in your system into the morning hours — when melatonin should be going away — so now your body thinks, oh, we must still be the middle of the night. Your body gets confused, so you feel more groggy during the day, but  have a harder time sleeping at night. It perpetuates the cycle.

most people are taking it wrong, taking too high a dose too late in the evening.

Is there something we haven’t discussed yet, particularly relating to midlife, that you’d like to highlight?

I would say one thing that's close to my heart is women's sleep health. Women are severely under-diagnosed when it comes to sleep apnea. And this is an especially important sleep disorder to recognize when the number one killer of women is cardiovascular disease, and sleep apnea puts a really heavy burden on the heart. Sleep apnea in middle aged women is a topic we don't speak enough about. 

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Why do you think that is? 

Even though women are less likely to have sleep apnea than men, we're much more likely not to be properly diagnosed because our symptoms are more subtle. Rather than the gasping, snorting and loud snoring physicians often look for, women with sleep apnea are more likely to be much more quiet and not breathe. 

During perimenopause, as estrogen starts to decrease, we have less muscle tone in our necks and in our airway. There are also changes with progesterone that make our body temperature higher and our sensitivity to CO2 a bit stronger. So women in midlife are not only much more likely to have sleep apnea than their younger selves, but they're also more susceptible to the negative impacts of it. 

women in midlife are not only much more likely to have sleep apnea than their younger selves, but they're also more susceptible to the negative impacts of it.

What would you recommend to women who are wondering if they have sleep apnea? These days, it’s increasingly common for people not to have a primary care or family physician. So what would you suggest they do as a first step?  

Very good question. So, if they have a good Primary Care Physician, the PCP can usually order an at home sleep study and can interpret that. That's often easier and faster to get; it's not as good of a diagnostic tool as the in-lab sleep study, but it'll point you in the right direction.

Then if you're fairly sure you have a sleep problem, then you might as well go straight to a sleep specialist. That might be a neurologist, might be a pulmonologist, might be a psychologist, biologist. Sleep is such a multi disciplinary area that it's hard to know where to start, but if you go to a sleep specialist, hopefully they can assess what your needs are and point you to the right specialist if it's not them. 

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Before we got started, you and I talked briefly about this moment in history we’re living in, and the collective sense of unrest and upheaval. Do you have encouragement for people who might be struggling to rest and care for themselves right now? 

Yes! You know, and I didn't coin this phrase, but rest really is resistance. We often think of rest as being lazy or unproductive, but feeding and nurturing our bodies, especially in a moment like this, is so important. It's not only a good way for us to take care of ourselves individually, but also collectively as a culture, to celebrate and promote rest. To fight against this capitalistic drive we've had since the beginning of industrialization, to use our bodies as tools until they're broken. It’s time we fight against that by taking care of ourselves through rest. 

Yes - Rest is Resistance is a phenomenal book and framework by Tricia Hersey. We have an article in this issue rooted in her work and perspective. 

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A sleep scientist’s origin story

Now, let’s talk about how you got into sleep science. I read that it all started with a childhood experience at a sleep lab - is that right?

It’s true. I grew up on a military base in China, which is not as serious and scary as it sounds, because it was actually the Chinese space agency. It's the equivalent of NASA, but in China, the space agency is technically part of the military. My dad was doing research with astronauts, trying to figure out whether sleep would change during space flight. 

We lived in the military base that was the space agency; so it was a smallish community where we all knew each other and I was babysat by the astronauts. As a kid, I would sometimes go to the sleep lab where my dad was working. I mean, astronauts are the coolest. And when you’re a kid, maybe the only person cooler than astronauts is your dad. So, sometime during that time, the seed was sown that I thought sleep science was a cool thing. 

Of course, as a teenager, I did not want to do what my parents did. So I wanted to be a philosopher, a poet and an archeologist. But at each stage, going to university, going to grad school, internship and postdoc, the choices I made somehow brought me back to sleep research. Nowadays, my dad and I talk shop all the time! We edit papers together and collaborate on data analysis. I guess the apple doesn't fall far from the tree. 

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You've been in the world of sleep science a long time. Looking back, was there a belief you held about sleep early on that you later realized wasn't true, or it changed for you? 

That's an interesting question. I don't really think so, and I give my mom credit for that. She was never a sleep scientist, but from the very beginning, she really exercised sleep health. She would make sure my brother and I got a good sleep - even if it meant not finishing homework sometimes. She always prioritized sleep for us, and I'm very grateful for that. 

Early birds and other myths

I think one big misconception that still persists today is the idea that waking early is intrinsically better. There is very much a stigma against sleeping in or sleeping enough. 

I think one big misconception that still persists today is the idea that waking early is intrinsically better.

We have sayings like, “the early bird gets the worm,” or Ben Franklin’s, “Early to bed, early to rise, makes a man healthy, wealthy and wise.” Growing up in China, we had famous parables; at least two of them were about young people who would stab themselves in the thigh with a sharp instrument to stay awake and study more. And there’s one where a kid ties his queue (his traditional hair braid) to the rafter so that if he nodded off, it would jerk him awake so he could keep studying. 

So we grew up surrounded by these cultural ideas that sleeping was lazy or a sign of a lack of industriousness. But my mom never believed that. So I never had to have a rude awakening. 

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Is there something that has surprised you in your own research?

If I could answer a slightly different question, I think it might be more interesting. 

There was a time when I thought I knew it all — I was already board certified as a sleep psychologist. I was one of around 200 people in the world who specialize in behavioural sleep medicine. I really knew my stuff when it came to sleep. 

And then I had a baby. 

Nobody talked to me about sleep. My health care team was great, but nobody gave me any perinatal sleep advice or knowledge, and I was having such a hard time. It was the first time in my life that I ever had a hard time with sleep. It rocked my world. 

So I went back and did research on my own. I scoured PubMed and went to conferences and went to specific talks on this topic. And I put together a set of information about perinatal sleep that still is not widely known. Women and doctors are not educated on these topics, because there are just a small handful of people in the world who specialize in perinatal sleep. I was shocked that I could get through a PhD, specialized sleep training, and board certification without having learned a single thing about perinatal sleep. 

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Do you see this conversation happening more now? 

I do see more conversations about this cropping up, and that's awesome. I'm also working on my next book, which will be on perinatal sleep, to help bridge that gap! 

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Living well

We're always exploring what it means to live well in midlife, knowing that “living well” can mean something different for everyone. What does living well mean for you in this phase of your life?

In this phase of my life, I would say, having a good relationship with my kids and having a sense of bond and ability to just enjoy them in all their glory — and also pain in the buttness that they are at this age, being very present with them. And I’d also say being in nature. 

So my very favourite thing in life — when time slows down and I can just truly be in the moment and feel like I'm living well — is when I'm hiking in the woods with my kids. For me, that's truly just the best of what life has to offer right now.

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Is there something that excites you most about this next chapter of your life?

I'm really excited about this phase of mastery that I feel I'm starting to enter into, especially as someone who's been pursuing higher education — I did my PhD, and then postdoc and fellowship after that. Most of my life has felt like I'm climbing a mountain. Like I'm reaching, trying to aim for a place where I finally have mastery of my area of expertise. And I feel like I'm starting to enter that. 

I’m entering it with a newfound humility, also. I don't even know remotely close to what I’d like to know, and yet I also feel a sense of mastery in my professional life and experience. I know what I like and what works well in these areas of my life. I'm starting to settle into myself as a real whole person.

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Thank you, Jade. It was lovely speaking with you. I appreciate your time and expertise so much.

Thank you so much for your thoughtful questions. It’s been lovely talking with you, too.

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