Track Your Sleep, It Might Not Be As Good As You Think

How to optimize your health using your unique sleep data, with Harpreet Rai.

One of the most impactful changes I have made lately is improving my sleep, namely my sleep timing.  This was inspired by tracking my sleep using an Oura Ring. If you have not tracked your sleep, I highly recommend you do. Even though I am generally not a big advocate of tracking, this is one area I feel is worthwhile. In today’s episode, I talk with the CEO of Oura Ring, Harpreet Rai about the many health benefits of sleep. Learn areas you can optimize using sleep tracker data (everyone is different). A great night of sleep is a huge health win, supporting everything from physical recovery to mental clarity.

In This Episode

Episode Intro … 00:00:40
Oura Ring, What it Is, What it Does … 00:07:10
Sleep Staging … 00:15:09
Causation and Correlation … 00:20:50
What Gets Measured, Gets Mastered … 00:26:37
What We Have Learned … 00:33:14
How Sleep Impacts Cognitive Function … 00:41:33
Episode Wrap-up … 01:00:46

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Episode Intro

Dr. Michael Ruscio, DC: Hey, everyone. Welcome back to another episode of Dr. Ruscio Radio. Today, I’m here with my good friend, Harpreet, who is the CEO of Oura Ring which is a small ring you wear on your finger and it tracks your sleep. Let me just say that this has been kind of a kick in the pants for me because I thought my sleep was not too bad. After tracking it for a while, it really pushed me to make sleep even more of a priority. I have to say the dividends that has yielded – my energy, my mental clarity – has been maybe better than 80% of the other stuff that I’ve done save treating an intestinal parasite. This is probably one of the top three things that I noticed a direct correlation to how I feel, which is prioritizing sleep, which tracking it really did help. Harpreet, we’ve been wanting to have this conversation for a while now and we finally got our schedules aligned. Thanks for being here and welcome.

Harpreet Rai:  Yeah, Mike, thank you.   I don’t know if you remember, I think the first time we met was … I shouldn’t even say met. This is bad. I was in the audience at AHS, Ancestral Health Symposium, in Seattle, I want to say three years ago. You were giving a talk on gut bacteria biome and overall health and what to do about it. It was super informative. I think for the crowd maybe a little bit controversial to some people, but I thought it was fantastic and I’m glad we got to meet briefly that day. But I’m definitely again, lucky, I feel like, to just have met you. You had a lot of community out in this world that were all trying to help. Finally, glad to be on the air.

DrMR:   I’m also glad that we met because it’s nice to have friends and colleagues who are trying to do big things in the healthcare space. Oura Ring, from what I understand, it has grown quite quickly, which is great to see because if we can help people better appreciate the importance of sleep, then that’s fantastic. I wish we could just tell people, “Hey, sleep more.” Yeah, that tends to be kind of akin to, “Eat better.”  People are really confused about what to do and if they don’t have some kind of guidelines and, in some cases, tracking to hold them accountable, they tend to flounder.  If people haven’t heard about you before, tell them a little bit about you, a little bit about the company, just so they … Before we launch into the nitty gritty, nerdy details of about tracking and all that.

HR:  Sure. I grew up a little bit all over.  I was born in Minnesota, but then I moved to the East coast when I was six, seven years old. I studied electrical engineering at the University of Michigan. Go blue for the alumni out there. What I studied and got fascinated by was really sensors and hardware. In Michigan, we had this program called MEMS, Micro Electronic Mechanical Systems. If you think about what that means practically to the average person – it is something that’s capturing motion, a sensor, that might be capturing temperature, how you designed those sensors. That’s become a specific technology within the engineering field.

Michigan had a great program for that, and I knew I wanted to do that going in. My dad was an electrical engineer, so that might’ve had something to do with it as a second-generation son of Indian parents. But no, I think, really, my fascination for the intersection of health and technology just came from growing up. I was a bad athlete. I had friends who could smoke a pack of cigarettes and run a five-minute mile. My sport was soccer, but I was not good. I felt like I had to work harder, learn about my body, learn about things like dieting and strength training as a teenager just to keep up and make the team. I think it was that passion for soccer, frankly, I think it’s a beautiful game, and then, also, I was always good at math and science in high school. Ultimately, sort of always knew even in college, I want to work in that space. I got distracted for a bit after college. I was “out of state” in Michigan, had a bunch of student debt, wanted to pay it off quickly. It was 2006, 2007 I was graduating in that financial boom.

So I went to a Wall Street, worked at an investment bank for one year, gained about 45 pounds in a year, almost a pound a week of 100% fat, probably lost a ton a muscle. I’m sure body comp was even worse. Then I ended with a little bit better lifestyle, at a hedge fund. But what really drew me towards the hedge fund was, was I was able to actually cover a certain sector and that was technology. I got to see it on the investing side and the public markets, companies from Google down to companies like Fitbit and some of the sensors that go with it.

So, that’s a bit about my background. I met the founders of Oura Ring almost about three-and-a-half years ago now, and saw what they were doing as soon as the Gen I ring had just, I think the Kickstarter had just launched, was really sort of blown away by what they had done. Knew some of the advantages of doing some of the sensing on your finger and also totally related to sleep. Got to meet them and we hit it off and I was able to bring a little bit of my business skills and the finance and provide a bigger picture in the world. Obviously, I think some of the technology that we have in our founding team is super, super strong. And I was really happy to leave the finance world and get back to my true passion.

DrMR:   Awesome. Well, it’s always good to have a road that brings you from, maybe, something else to what you’re meant to do. I think that little bit of a juxtaposition helps us realize hey, as cool as this is working in Wall Street, I’m sure it’s probably cool sometimes you felt like, Joe hot shot, you had this passion that wasn’t being fed. Now, here you are, obviously feeding that passion. Tell us a little bit about Oura Ring. People haven’t heard about it. Get us up to speed on what it is and what it does.

Oura Ring, What it is, What it Does

HR:  Sure.  Our mission is to help consumers, to help people own their potential. What does your potential mean to you? For us, we both have a podcast, we both want to appear sharp, right? People want to have high energy. We also want to be able to think clearly.  But maybe we got some exercise instead and we want to perform well in the gym. We’re obviously focused on our long-term health. Turns out that all these things, all these dreams that we have are literally powered by the benefits of sleep. We as a company, decided to focus and start on sleep. But obviously, our goal is to help you improve your life.

We believe, like you were saying, there’s this unique power within us, something magical about sleep that we’ve gone away from as a society that actually fuels literally everything that we want to do, all of our potential. Our view is that by helping people improve their sleep, we’re going to improve their lives. That is why we’re focused on sleep and recovery, how it can actually improve your whole life. Like you were saying, there’s a ton of science we can get into.

In terms of what the product is, yes, it is a wearable device. It is a wearable ring. We don’t refer to ourselves like that internally, but there’s a scientific reason that we can get deep into, I mean basic 10 seconds. It turns out measuring your heartbeat on your finger, just like every hospital does, is about 50 to 100 times stronger pulse strength than anything on your wrist. And so, that’s sort of why it’s a ring and sort of why the focus on sleep and recovery.

DrMR:   You were kind enough to send me a ring maybe almost a year ago now. When did the Gen II release?

HR:       Yeah, it’s a really good question. We did a pre-order for our Gen II just like we did our Gen I Gen I we did on Kickstarter.  Gen II we actually did our own website. That launched as a pre-order just about two years ago.  Then we started shipping, which was a little slow at first. Took us some time to finalize, getting our full manufacturing scaled up. We, in earnest, just started shipping these about a year ago. Consumers have had to wait a long time. There’s been more demand than predicted, which is great. And we’re, I would say now, we’re finally shipping like a real company, in a few weeks and hopefully soon it’ll be a few days.

DrMR:   I just wanted to make sure my timeline wasn’t totally off.

HR:       Nope.  You were one of the first that got a Gen II Oura Ring.

DrMR:   If Tim Fitzgerald, who owns the local U.S. Cryotherapy Center in Walnut Creek is listening, he was kind of irked because I got one, I think, six months before he was supposed to get his. But I’m happy that you made the exception and sent me one early because it gave me a chance to really test it. Like I shared at the start of the podcast, I didn’t think my sleep was bad, but just one insight I’ll share,  I’m sure there will be many through this conversation, I realized that if I can get to bed between 10:00 and 10:30, my sleep quality is vastly better than if I get to bed between 11:30 and 12:15.

I try not to sweat the small stuff, but I also remain open to, okay, maybe sometimes you have to be a bit more strict, and this has been one case where it’s like, wow, my sleep quality is just way better. I feel more refreshed, I sleep more deeply, and then where I really see that reflected is on the ring. The cool thing about the ring, I’m looking on my phone right now because I literally check this every morning because it’s kind of a love hate sometimes. I’m like, “Darn it. Why isn’t my sleep quality better?” But I think oftentimes that comes back to things within my control, like I had some alcohol or was up too late.

But you see, total sleep, efficiency, restfulness, REM, deep sleep, latency and timing. It’s been really helpful, to track this and to see I may have enough time in bed if I went to bed at 12:30 but my latency shot up. Which makes sense because my body tends to wake up between 7:00 and 7:30 and then I can kind of force myself back to sleep and try to get my full eight. But my latency gets pretty terrible and then everything tends to follow behind that – deep sleep and REM sleep and whatever else. I mean as I’m rambling here and sharing some of my experiences, anything that you want to tack on to?

HR:       Yeah. There’s a lot there to unpack. Let’s take a step back, just starting with a big thing you started with, sleep timing. I think if you look at the human body and the way it was designed, we were meant to start to fall asleep when it starts to get dark out. Obviously today, we have indoor lighting with the advent of the light bulb and electricity and now even things like solar and other cool technologies allows us to live in an always on culture. I think first it started, really, just with electricity. But obviously that’s moved into the internet and that’s moved into even mobile phones. So we are now living much differently than our ancestors did.

If you think about certain things like the body and the brain and your hormonal system and things like circadian rhythms, literally, when it gets dark out, the sun goes down, what happens is melatonin starts to get released. In nature if we were all camping outside, we’d be exposed to blue light in the sun. That blue light, once it goes away and the sun goes down, triggers your brain to release melatonin, which gets you tired, which also triggers a bunch of other hormones. Turns out your liver shuts off a little bit, it doesn’t actually process sugar as well later in the evening or night

There is reasoning behind why you actually sleep better if you go to bed at an earlier time. Now, everyone has a slightly different optimal windows and having an Oura Ring actually lets you determine that. Like you said, if you go to bed earlier, for you, obviously, it’s a little bit different for others, you’re able to get better deep sleep, better onset, fall asleep quicker.  You’re not tossing and turning, and you wake up and you feel great. I think the other thing you mentioned is, you sort of have this love-hate relationship with checking the data and sort of knowing how you feel in the morning.

Honestly, I think we’re sort of, in that sense, almost like the technology for good. Every day, every listener who’s listening to this podcast, when you wake up in the morning, whether it’s with alarm or naturally, before you put your feet literally on the ground, you sort of ask yourself, how do I feel? Some people ask themselves that for five seconds. Some people probably ask themselves that for 45 minutes, looking at their phone before they get out of bed, sort of dreading the workday, or just feeling low energy. All we do is extend that moment of self-reflection. We cause you to look back with it and we give you a little bit of data.

That’s something that I would say is helpful every day that then makes you start to think about it, “Oh man, I slept like crap yesterday. Guess what? I’m going to cancel that podcast with Harpreet. I know I’m not going to be at my best.” Or, “I’m going to try to get to bed earlier. I’m going to maybe go a little bit easier in the gym or even harder. I’m going to pay even more attention to what I eat today because I know I’m sort of behind the eight ball.” So I think that’s really just talking about sort of big picture on some stuff you just mentioned on your data on why we go to sleep or why you sleep at a certain time and also, that feeling that you have in the morning.

DrMR:   For me, the biggest insight was, and this is one of the things that Dan Pardi has said multiple times, some of these wearable devices may not be as accurate as the gold standard they’re trying to replicate. We’ll get to this later because there has been one comparative study looking at a polysomnography, and a sleep study compared to the Oura Ring. But Pardi’s point was that they may not be as accurate as the gold standard, understandably so. One is a wearable device that’s super convenient. The other, you have to be in a clinical setting.

Sleep Staging

So oftentimes the non-gold standard test is, perhaps, less accurate, but it also has clinical utility. And so, in this case, what was helpful for me is that I was getting a better awareness in terms of why my sleep wasn’t good, and it made it much easier for me to see, “Boy, when I hit that between 10:00 and 10:30 window, all of my sleep measures look better and I feel more refreshed.” Perhaps I would’ve figured it out over time.

But I think the thing that kind of made me more motivated to get to bed earlier was having enough data staring me in the face showing, “I feel like I sleep okay. But this is telling me I’m not sleeping that great. Maybe I could do better.” I gave it a shot to do better and it was like, “Wow”!  Subjectively, I feel much more refreshed in the morning, I have better energy.”  That’s where I think some of the biggest utility is, is just in guiding our awareness.

HR:       I would say, you and Dan are absolutely right.  These devices are not a substitute for a full 16 to 32 lead polysomnography test. But we have designed it where the data feels right, and you start to change your behavior and you sleep better and the data says you sleep better and you feel better. There’s a reason for that. To dive a little deeper, and I know your audience is pretty scientific, especially, just getting some of the guests you’ve had on here who are real scientists, I think there’s two things to think about there.

One, if you look at sleep staging as a science, like what is it, the way that scientists and doctors have come up and adopted sleep staging, they’ve gone and looked at brain waves, right? And have basically found that your brain waves change throughout these nights, throughout the night, in certain patterns. Turns out your brain activity slows down when you go to sleep, literally the frequency of the neurons that are firing, the speed at which they’re firing slows down and goes as slow as one to two Hertz. Typical daytime activity, your brain is firing at greater than 50 Hertz. REM sleep is actually, sort of, where your brain is still a little active, in that 50 to call it 20 Hertz range as it starts to slow down. Light sleep is below that and then deep sleep starts below five Hertz.

The reason I’m giving you this explanation is because when you think about sleep staging as a science, scientists or doctors will classify you based on the frequency of those brain waves. Turns out there’s a lot of variation night to night and even within the night.  There’s going to be two-second periods where it looks like you’re in light sleep, One-second periods or half-second periods that looks like you’re in deep sleep.

And so, what doctors have to do is actually make a judgment call on a lot of this data that looks like it’s in between sleep stages. So if you took this test and we went to Matthew Walker’s lab right near you at Berkeley, and then we went to, let’s say, Andy Crystal’s lab here at UCSF, what we would find is actually, depending on the score and who looks at the data, they’d have about 80% agreement. So just like a blood test, a glucose test might have a 6% standard error. Turns out, that the standard error in sleep staging and sleep tests is about 20%. At Oura, we think we’re about 10% less accurate than a sleep test. There was a validation paper done by SRI that was done on our Gen I ring. Luckily, we’ve been able to keep improving technology and the accuracy and we look forward to having validation paper done on Gen II.

We know this is an issue, this is always an issue, for every sleep tracking company. No wearable will ever be 100% as accurate as a sleep lab because of this issue. But we try to get as close as we can. One way we designed our algorithms was to think about, how do we still capture the changes night to night, on a relative basis? This is sort of called precision over accuracy. What that means is if you have a scale, it’s one pound off every day. You can still see if it’s off, that consistent one pound, if your weight is going up or down. And we designed our algorithms the same way in sleep staging.

So even if we’re less accurate, we have focused our algorithm on something extremely precise. You can see that night to night change. So, when you go ahead and eat a light meal or have ice cream, pretty late at night, and have a ton of sugar and are watching TV and alcohol, doing all the bad things, maybe some pizza, too, you’ll see that data reflected in your sleep staging. Did you have 45 minutes of deep sleep last night or 30 minutes? That data may be off in terms of accuracy, but did your deep sleep go down at night? You did a lot of bad things. That’s what we try to be precise about. That’s a scientific and mathematical explanation as to why you say, “Hey, the data reflects how I feel.”

DrMR:   Yep. I think that’s right on with my experience. I know that’s what Pardi has posited also. I think it’s important to mention that, no one’s proclaiming any of these devices to replace a sleep study, but it’s rather to help give you some biofeedback and bring some awareness. Just to chime in on one of the factors that you mentioned, alcohol.  I’m always trying to optimize, I’m always trying to get away with the most stuff, and so I started saying, “Well if I’m drinking and that drinking is making me stay up late, and I’m seeing bad sleep, the sleep disruption could be due to timing or to the alcohol. So, I’m going to run some experiments and I’m going to go out and drink, do that earlier, still get to bed between that maybe 10:00 and 11:00 window.”

Causation and Correlation

What I noticed was that the alcohol itself can be a definite deterrent to sleep. That’s nothing new. But again, for me, just having that data helped me really see that maybe feeling tired the next morning isn’t so much so a byproduct of being hung over. Because oftentimes, I wouldn’t be drinking near enough to really cause a hangover, but it was more likely because I just had a bad night’s sleep. Then I start recalculating, how worth it is it to have more than one glass of wine with dinner? That starts changing your behaviors.

HR:  We’ve seen that behavior from so many of our users. I think alcohol is one of the more apparent ones, when people drink and then see how bad the data really is. This is going to sound not believable to some users, but some of our users would feel the same way.  For myself, if I have a late dinner or if I have ice cream, I almost have a worse quality night of sleep than I do if I have a beer or a glass of wine.

Everyone reacts differently, that’s the most important part. You need a tool to figure out what’s working for you. Luckily, we let people do that.  We found some people, they cut out coffee right around noon, which you would think is okay. But they found they were actually really sensitive to caffeine. If they have coffee around 12:00 or 1:00 PM they found out that dramatically impacts the quality of your sleep.  For a lot of people, alcohol is a big one.

Then we see people changing their behavior. You have a little bit of data against how you feel and then you tend to remember it a little bit more and you have a little bit more causation and correlation. Then people start to change their behavior and then they feel better. So that’s literally why we made Oura. We wanted people to eventually understand what’s working or not working for them. What lifestyle choices they are making that are working out really, really well and which ones are not working out so well. Then be able to actually improve their health and their well-being.

DrMR:   It’s a great point because one of the things that I would imagine eludes many people, if whatever the factor is interfering with one sleep doesn’t cause a massively negative impact on how they feel the next day, it may keep them from making the connection. I think for me, I never felt terrible when I went to bed at 11:30 – 12:15 but I was getting this data from the rings and my sleep wasn’t looking good. That motivated me to make changes and then I got this biofeedback where I said, “Wow, I wasn’t feeling bad before, but I don’t even feel like I need caffeine today.” Just as one example.

HR:  Right. Why do you think that is?   I’m just curious from you personally, and I’m happy to speak about my personal experience as well, why do you think that you felt okay before, but now you have a better idea of how you’re feeling?

DrMR:   It’s a great question. Perhaps, I hadn’t given enough time and attention to sleep. I think I was making some presumptions that my sleep was good and didn’t really need to get any better. That was probably just me not understanding that, for my body apparently, or at least for right now, getting to bed a bit earlier makes a big difference. I don’t think I’d really ever run that experiment enough to be able to figure this out.  I think what the Oura really provided me with was just the prompts to do a little bit of experimentation.

Then once I saw the results, it was kind of like that old saying of sometimes don’t realize how bad you were feeling until you start feeling better. I wasn’t feeling terrible, I maybe just got a little bit accustomed to having a little bit of a midday slump, using a little bit of caffeine.  Perhaps there’s a subset of people that they’re doing pretty good. So that thwarts them from looking for areas of optimization because it’s not bad enough to prompt them to do anything, and they’re in this kind of weird no man’s land.

HR:  That is a good way to say it. How many of us have probably had this? A sports injury that was bad, but not bad enough to sideline you.  You get used to it every day, and then you continue to keep working out. You continue to keep lifting, you continue doing whatever you’re doing, and it slowly gets worse and worse and worse, where all of a sudden, it becomes unbearable one day.

I’ve actually had a torn labrum or a herniated disc for months if not close to a year and I think it just becomes a new normal. Which makes it hard for us to figure out really how should we feel.  That’s a little bit of it.  The other part is, frankly, in today’s society, we’re just in such a rush all the time, that we don’t really have a moment to pause and think about how we feel. Literally the average person’s getting over 150 messages on their phone in a day. That translates to literally one every six minutes during the waking hours if you’re up for 16 hours.  It is hard to honestly think how you feel when you’re being distracted that often.

What Gets Measured, Gets Mastered

The last one is really, what gets measured gets mastered. Just like you have a dashboard for your business. We have a dashboard for bank accounts.  You have a dashboard on your car for when they check engine light is or how fast you’re really going on speedometer. Otherwise, it’s sort of hard to know. Am I going 60 miles an hour, 65, 70, 55?  I think just being able to dial that in with data, with science and technology, lets people experiment, reconnect with really how they feel. Think about it just a little bit longer, and then ultimately change behavior and that’s what we see. That’s what we find all the time.

DrMR:   Again, just to make sure we frame this correctly, because I do think it’s important, not to hold any of these devices out as replacing the gold standard, but you really don’t need to. To see benefit from it, if you have improved awareness, and that moves you to take action.  I’m sure there are some who would say, “Well it’s no better than a sleep study.” Again, it’s not meant to replace it, but I do want to touch on that pivotal paper, for our audience this is a validation study that is in PubMed.  The Sleep of the Ring: Comparison of the ŌURA Sleep Tracker Against Polysomnography.  What’s nice here is at least you guys are, first of all, participating in research. There are some devices and some supplements where people are making pretty laudable claims and they aren’t doing any science and exposing themselves any kind of scrutiny. So firstly, I applaud the fact that you guys are putting yourselves out there and willing to go into a scientific setting where you can be scrutinized and learn strengths and weaknesses. There’s really a silver lining there because any weakness gives them an area for potential improvement.

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I’d also like to thank and tell you about the Oura Ring. The Oura Ring is a comfortable way to track your sleep and your recovery. It’s a small ring. It’s not tight. It doesn’t have any flashing lights like many of the wrist devices, and you obtain helpful data.

A morning HRV, or heart rate variability, plus a daily readiness score, which is partially based upon the HRV plus sleep data. And you get a sleep score as well as breakdowns regarding timing (very helpful for me), restfulness REM sleep, and deep sleep. I’d highly recommend if you’re looking for a way to keep your sleep on track, get an Oura Ring. If you go to the URL OuraRing.com/ruscio they are offering for a limited time, $50 off.

I don’t want to put you on the spot here, but do you have any takeaways from that sleep study that you want or that comparative study looking at a sleep study compared to the ring, that you feel are worthwhile to elaborate on?

HR:  I would say a couple things. Maybe taking a step back to see the bigger picture.  If you just think about what the world spends on health. Because we are talking medical research now and I think it’s important to take a step back. Today, as a society, we spend globally something like 7.5 trillion on healthcare.  That is Medicare, Medicaid, insurance, everything, all combined together. The Global Wellness Institute has put out a number, I want to say it was like 4.95 trillion last year on wellness spend. So outside of the insurance space what consumers are spending on health.

If you’re payout out of pocket to a gym, going to get an IV, a vitamin IV, whatever it may be. Supplements, personal training, diets, functional medicine doctors that are outside of insurance system that, I think, either way you look at it, seven and a half trillion, four-and-a-half trillion combined, really, really massive numbers here. We’re talking about north of 10 trillion combined. I think the key to helping people improve the efficiency of that spend and get more out of it, is going to be better health, data, and technology. Really better data in technology.

So, our view is, we want to make a consumer device that is the most accurate consumer device, so people can actually understand and learn the most. That in the future can be medical grade. I feel like these lines are blurring more and more.  It’s in the DNA of our company, everything we do, we measure against the gold standard. Whether it’s heart rate and chest straps, whether it’s sleep staging and brainwaves, that’s what we do. That’s who we are. That’s why we made it a ring as well, versus something on your wrist.   I mentioned this briefly in the beginning of our conversation.  You have the arteries on the inside of your wrist. That’s where you learn as a kid to measure your pulse. Those arteries go to the palm and the fingers of your hand and you can look at your skin on your palm and it’s really, really clear, thin and that’s where your hands look reddish. Turns out that allows for a signal strength on your pulse. That’s about 50 to 100 times stronger than that on the other side of your wrist where your Fitbit, Apple watch, some wrist-based wearables sits. So, we literally made this a ring foremost for science, and, like I said, as a result, we do think these spaces are going to blur and so we need to be able, in the future, to keep innovating and keep getting better, to keep getting more accurate.

What Have We Learned from the Research

What did we learn in our study?  We learned that we still have a long way to improve. We were happy that we were able to get a study published independently, meaning we didn’t have to pay for the study. That is actually really huge. You can talk to Dr. de Zambotti at SRI who did that. He literally just bought the rings himself off of the Kickstarter on our Gen I. He had two rings on, on 44 subjects. So, I think sizing was a bit of a challenge. There’s definitely some probably not the best signal quality, but despite that, I would say we looked at that paper. We were really happy we were able to get an independent publication that, we didn’t have to pay for, felt like it was really good science. I would say Massimiliano or Max is really well-respected within sleep industry.

It set a goal for us as a company that we want to make sure we’re going to be the most accurate against PSG.  Internally, we’ve been improving quite a bit since then. We’re still happy with those results. We’ve improved even more with Gen II. We’re looking to validate that. But we’re working with lots of universities.  We have a couple of things going on at UCSF. We have some more stuff in the future at the University of Helsinki, University of Oulu, both in Finland where our company started. Even working with some other universities within California and Texas. We’ve seen a tremendous amount of interest in the scientific community and I think when they hear us understand why we made the product what we did, why we’re trying to actually work with researchers and work with medical grade type technology, I think it gets them excited and I think that’s what the world needs.

Today it’s really hard to distinguish between what’s real and what’s not, what is a gimmick and what’s not.  The wearable industry has gotten a bad rap because of where it started. I think it started first just focusing on steps and then more and more research came out and it turns out that steps aren’t that imperative to our health. I think there was really good study in Japan that was pretty large, hundreds, if not a thousand subjects, that looked at people doing 10,000 steps and they tended to eat more so they were actually gaining weight, not losing weight.  I think it was a clever idea to start with, creating a step tracker that we used to wear like a pager, like a pedometer, into a digital watch. I think that was really, really smart. I do think it does help promote positive health behavior over time. I think now, as the world of sensors has evolved and gotten better, we’re all in this race still. “Hey, how do we help people improve? How do we use these sensors to capture more accurate data so we can eventually drive better health outcomes?”

We’re super happy to be part of that effort.  That’s what gets me excited every day. That is 10 trillion year that’s being spent in mostly the wrong way. We’re either waiting until our engine dies in our car, like we have a heart attack, and then we are part of that larger medical spent in, that goes through insurance. Or, “Hey, we’re trying X, Y, Z supplement. I’m trying this, I’m trying that, maybe I’m doing a colonic, I’m trying to do everything I can to get rid of SIBO or parasites” or whatever it may be.   It’s hard for consumers to know what’s working. Our view is, with the right data, with the right insights, you can unleash your true potential. That’s why we’re so excited to do what we do every day. Getting back to science. That’s at the heart of how the organization was formed.

DrMR:  As you’ve been kind of culling through the data here, or just in your own experience with talking with people and being ensconced in this space, have you learned any insights, tips, or tricks that you think are worthwhile for people to know about?  From the perspective of user insights, correlations between either learning about one’s behavior, motivating change, changes that one may see shared on their Oura Ring score?  Are there any inferences being drawn from if there’s chronically low deep sleep, does that mean X? Anything on the user end that people should be aware of?

HR:  I think Matthew Walker has sort of said it the best. That sleep is the world’s best legal performance enhancing drug.  The benefits that we derive from sleep, the majority of our growth hormone and natural testosterone is all released in our sleep. How we learn, literally, how our memories are made every day, are formed in our sleep. Turns out, not enough deep sleep, for example, will actually most likely cause the early onset of dementia and Alzheimer’s. There’s been two new papers with evidence out suggesting that in the last three years. So, sleep is just so crucial. I think beyond what we’ve realized as a society.

In terms of Oura users, making it a little more practical, what we’ve seen on how people are changing their behavior.  Like alcohol, even just one glass people are like, “No way. I feel fine after one glass, not even buzzed.” Totally increases your resting heart rate at night, lowers your HRV, tends to actually decrease deep sleep for most people and even REM sleep, and you’ll toss and turn more. But we’ve found that even what time you eat dinner, what you may eat for dinner, how much exercise you get, we found so many users that found that they’re over-training.  That working out at 100%, 110% speed.  That mindset of “there’s only one speed and that’s game speed”  Well it turns out that with all the stress that we have in our regular lives and the lack of sleep that we’re getting, that’s not enough to recover from a grueling workout every single day for people.

We found people that start to actually adjust their workouts, workout less, and have better results.  They actually have higher strength gains.  We have found, for so many people, it has changed all types of behavior. I remember one person reached out to us.  He’s a Spartan racer. He’s 50 years old, has a six pack, he’s totally ripped and in shape, but he always felt like sleep was holding him back. He got an Oura Ring. He had low deep sleep and his wife has been complaining for 20 plus years that he snores a lot. This is a guy who’s perfectly in shape, super lean body mass, gets tested for sleep apnea. It turns out he has it. He gets a sleep apnea machine. He improves a little bit. He doesn’t have as many disturbances, but his deep sleep still low. Turns out, he has a cup of coffee, his last cup of coffee every day at 3:30 or 4:00 PM. He cut that out, and his deep sleep went through the roof.

DrMR:   No kidding. Wow.

HR:  Yeah.  He has been Spartan racing for I don’t know how many years.  Then, after finding all of this out, just this last year, he won first in his age group.  He’s never won first in his age group, ever.  I mean he did it multiple times this year in a few races. I think we’ve heard all types of stories that really inspire behavior change. But the other thing we’ve found is everyone’s different. It’s not one size fits all. Some people get really, really high reps and some people get really high deep sleep and some people are low in both. We’ve found that people use this as a self-exploration tool. It really starts to dial you in and causes positive behavior change.

We’re really excited actually. I do think there’s going to be at least a manuscript published to a medical journal, submitted to a medical journal in the coming month at UCLA. That shows how looking at sleep with the Oura Ring and they looked at a couple of different devices, how the Oura came out on top, actually promoting behavior change and positive health outcomes. It’s a small study, but we were very pleased when the head of research reached out and said “You won’t believe it. This was awesome. I’m so glad that I heard about this and learned about it.” He learned about through a podcast, he tried it personally, and then he ran a comparative study, so we’re super excited to see the results.

DrMR:  Man, that’s fantastic news. That’s an amazing story about that gentleman with the apnea. If anyone in the audience has not listened to our podcast on sleep, published about two years ago, definitely listen to it. I essentially just read through select citations from Healthy Gut, Healthy You chapter on sleep.

How Sleep Impacts Cognitive Function

The data here is incontrovertible. Sleep affects everything from your metabolism, to your brain health in a remarkable way. I’m not talking a small effect size. The meta analyses here, I felt like a kid in a candy store. Every health parameter I wanted to look at had a corresponding meta-analysis and they’re all showing essentially the same thing.  The data there are so clear.

If there’s anything that you can do to prioritize for sleep, do it. That’s been said by pretty much every health guru that I know from Dan Pardi to Rob Wolf to Mike Nelson. Anyone who I respect has pretty much had the same position on sleep. There are no heretics out there saying, “Ah, sleep is over blown.” One other thing that popped into my mind while you were describing this, one of the things that we’ve talked about on the podcast prior, are brain games, evidence-based brain games that have actually been published and shown to improve various parameters of cognition, or other neural function.

I just remembered this. Last night I did everything wrong. I went to the gym way too late, had caffeine too late and I had a feeling I was going to have a pretty bad night’s sleep, which I did. This morning, as part of my morning routine, I did 15 minutes of brain games. I notice a clear diminishment, when I have a bad night’s sleep in my cognitive function when I play these brain games. There’s one in particular, that involves 10 Lily pads on the screen, and they light up in a different order, and then you have to remember that pattern and trace it in reverse. Doesn’t sound incredibly hard.

But when you have 10 Lily pads on a screen and they all light up in a different order, and then you have to remember that backwards, you have to be at full function to really get that. This morning I was just getting crushed by that exercise even though two days ago I was doing it fairly easily. So just a good reminder there from my own experience that cognitive function can definitely be tanked by just one bad night’s sleep. So if you’re a clinician especially, and you’re dealing with complex cases, you would need to be on, and again, that’s where something that can help you and motivate you to sleep better will yield huge dividends for your neurological function.

HR:  Honestly, this is probably the most important part about sleep that I think is overlooked, neurological function and mental health. But what our average user is thinking about is productivity. The majority of Oura Ring users today are optimizers. They are people that are trying to improve their health. They’re probably not at their peak like they used to be when they’re 21 and playing a ton of sports, or 18.  But like the NCAA commercials, 99% of us will go pro in something else. It turns out that most of those other things, you need your brain even more than your body. Obviously, pro sports, you need both.

It turns out that sleep has such a tremendous impact on cognitive function that I think we’re only now beginning to really understand. There’s been studies done, I think, for athletes and showing reaction time. I honestly think the one that was so eye opening to me. Dr. Benjamin Smarr, Berkeley circadian postdoc, did a study involving thousands of students, I can’t remember the exact number. What they did, really simply, was they got access to student records of the login times on the student network and computer.

What they found is students who had most likely the shortest amount of sleep, and all they did was look at the login and log out times. How late were you up, essentially logging into the computer network and then when did you log out, and then when did you log back in. What they found was a direct, extremely strong correlation to literally how much you slept based on that proxy and your grades.  I remember how competitive it was in my engineering program at Michigan.  There was this one kid, Percy, I can’t even remember his last name, he was a genius.  He was a triple major, got his PhD in mathematics, a PhD in Econ and he got a Masters in Electrical Engineering in three and a half years, and he had a perfect 4.0.  And I asked him once, “Percy, what is your trick?” He was like, “I get eight-and-a-half hours of sleep every single night.” I was like, “You’re kidding. Right?” He’s like, “Nope. Every single night.” And he was like, “I don’t even look at any books the day before an exam.” Then you look at some of the scientific evidence that we’re starting to see, and it turns out memory and cognition are directly linked to sleep.  The more you sleep, the better memory consolidation will be, and also the better you will actually perform and be able to recall those memories and learnings. Most of our users will tell us the reason they try to optimize their sleep is because they want to be more productive.  The majority of us are knowledge workers.

You and I for example.  Obviously, you have the clinic, you also have a business, you have the podcast, you have a ton of other things you’re doing. I’m running a company with over 90 people now. Being on top of my game and making the right decisions every day on the hundreds of things that people may try to ask me, you’ve got to be quick on your feet.  That’s the key.  For the average, everyday person, they want to be more productive. They want to have more energy.  That’s what most people are saying, why they’re trying to optimize sleep.

I think a lot of our audience luckily has come through, really influential people like yourself, people that have dug deep on health. I think they understand some of the benefits of ghrelin and leptin.  When you get less sleep, six hours versus eight, what that might mean for fasting insulin levels, fasting glucose levels. But the majority of our users will say the biggest benefit they get is exactly what you said, increased productivity.

DrMR:  Well, you know, what else is really interesting from the story of the competitive athlete. I think that people may be suffering from sleep impediments and they don’t know it. This is something that Dr. Mark Burhenne, a dentist who was on the podcast maybe three years ago.

His book is called The Eight-Hour Sleep Paradox, and it’s excellent. I highly recommend it. It’s only maybe 120 pages. It’s a quick read, but it’s chock full of examples of indicators that your sleep may not be good. He even goes as far as to show you diagrams of if you have a crease down your tongue, that may mean that your tongue is being folded in on itself by your mouth, as mine actually is. That may be secondary to having had tooth extractions and braces when you were a kid as I had.

That can lead to impediments in the oral airway, decreasing sleep quality, which is now something I’m actively investigating.  Trying to see if I can get my Oura data essentially perfect because it has gotten better. With the Oura data, you get every bar is either blue or red the next morning. That tells you, okay blue is good and red obviously is bad. I still have some latency deep and REM sleep, orange bars. I’m wondering if there’s an issue there that’s present. But the whole inception of my curiosity about this came from the Oura data.  You can make the argument, I could have figured that out without Oura, but for me, and the reason why I really am kind of waking up to the utility of these wearable devices, is because I’ve been led in this crusade to optimize my sleep, and so far, it’s paying off big time. I wonder, maybe I have some crowding in my oral airway and I need to use an expander device to open back up some of my jaw and nasal, oral airway so I can sleep better at night and see an improvement similar to what the Spartan racer found.

I really am curious if, for many people there’s this blind spot in their sleep, because it’s not easy to track. So that’s why, again, even though this is a newer device and the data is early and we’re still figuring out a lot about it. But boy, if it can help someone, like it’s helped me to make sleep quality more important in their life and also potentially look for, “Well, why are my readings not that great?” Then we certainly can make a safe inference that because sleep is so important, if you are motivated to improve, you could yield some pretty lofty health dividends. I don’t get excited about things too often because I feel like there’s a lot of over promising and under delivering, but this is definitely something that’s got me pretty excited.

HR:  That’s awesome to hear. I mean, I guess from a statistical point of view, I think you’re right, there’s probably a lot of issues, I think, with people with sleep apnea or some type of, honestly, just restricted breathing.

DrMR:  Yeah. And sorry, I don’t mean to cut you off, but you said sleep apnea. I want to make one distinction, and Burhenne also makes a distinction.  It is that his view that there’s a subset of people that aren’t bad enough to be qualified as sleep apnea.  And there’s a couple of different terms that are used. I don’t recall off the top of my head, but yeah, and that’s where I think this could also be very helpful, and some people may fit into that, not bad enough to preempt a sleep study, but they still could have things that are a problem in their sleep, which is the exact camp I think I may fall into.

HR:  I think you’re absolutely right. I think the oral pathways and breathing in through your nose as well. The amount of restrictions that we probably have, to the everyday person is probably pretty large. I feel like majority, I don’t know this, but if I had to look it up, a majority of Americans have probably had some type of dental issue. But we just go and look at the teeth. There isn’t enough work being done on how you’re breathing. That affects, not just at night, which is, I would argue, the most crucial time, but also even during the day, even during athletic performances. So that’s an awesome example. Thanks for sharing that story.   We’ve heard similar things from a lot of our other users. Some have found that even just mouth taping, some people have moved to just wearing a retainer, getting some type of oral appliance that actually helps improve breathing. But I wouldn’t be surprised if that’s probably one of the biggest causes of poor sleep.

DrMR:   Yeah, I agree. That’s why we’re going to be doing more interviews on this topic. But what brought us here, was I started looking more closely at sleep. I made some lifestyle changes. It got better, but I’m still not seeing … I hate to use the term perfect, but I guess I’m aiming for perfect and I’m still not satisfied with how close I’m getting to it.

Now I’m saying, “I read Burhenne’s book and it’s like, yep, had a tooth extraction. Yep, had braces. Yep, had headgear. Yep, have a fault line down my tongue. Is your sleep not perfect?” Well, it was, apparently pretty bad. It’s gotten better. It’s still not perfect. So yeah, I have an appointment with a dentist on January 21st to get checked out and I’m excited about the potential. If I’m operating at this high of a level now, and my sleep’s 20% impaired, just to use an arbitrary percentage and I can fix that, kind of feel like I’d be unstoppable, which would be great.

HR:  I think, I forgot to mention this. The Apnea Hypopnea Index, AHI. Basically, you need to have a certain number of pauses in breathing to be classified as severe sleep apnea, and it’s greater than 30, which is just nuts. That’s purely shallow breathing on average each hour. I think most people that might have even, what might be considered mild sleep apnea, five to 15 of these indices, or incidents per hour are not given, much of a solution. I think oftentimes they go; they’ll get a sleep test done, they have some type of restrictive breathing, but it’s not severe enough to warrant a CPAP machine.

Honestly, probably the majority of those are exactly what Dr. Burhenne said, right? Some type of mouth way, it might be nasal or might be actually through a mouth, some type of breathing issues. I think the more important takeaway that could be one of the reasons people are receiving, the benefits of correcting these issues.  Our bodies are literally a miracle. Sleep, if you think about it, we formed how to sleep, when we were all conceived, all of us listening to this podcast. A sperm and an egg coming together and forming into a fetus. We spend the majority of that time in the womb, in sleep mode.  That’s how the body is forming. Just think about that.

That’s how we actually form, and it turns out every night when we go back to that recovery period, that formation period, all of these things are happening. Our brain is literally clearing out the toxins from the stress of the day and inflammation during the day. Our testosterone, our hormones are being reset, our ghrelin, our hunger hormone, our leptin, how satiated we are, how full we feel, being reset. Our natural blood pressure medication that’s released into bloodstream, reduces our heart rate. Sleep is invincible. All of this power is within us. It’s often, the one thing we all overlook. There’s better technology coming that’s going to help people understand this. Honestly, I think it’ll be the keystone to understanding our health in the future.

DrMR:   I fully agree.

Dr. Ruscio Resources

Again, everyone, we’ve discussed how important sleep is and hopefully, my story will motivate you to give your sleep a deeper look. Whether you use an Oura Ring or not, or you just start taking a mental note, or you read Bruhenne’s book and go through some of his self-assessments. I hope that you’ll recheck your sleep, because I thought mine was pretty good and again, it wasn’t bad, but what’s our relative gauge point going to be? The standard American who’s overweight and has at least a couple of diseases and diagnoses? Or is our relative gauge going to be someone who is at a healthy body weight, has good energy, has good cognition, has healthy looking skin, and is present.

This is one example, at the end of the day now, work, family obligations, chores, and I still have energy to play piano, which has been a struggle for me, but as my sleep has gotten better… Last night it was, I think 9:30 and I was learning how to play Christmas Time is Here by Vince Guaraldi, which is a pretty challenging jazz piece. Sometimes you have these moments when you look at yourself doing stuff and you say, “Boy, I really would not have been doing this six months ago. I would have been on the couch, watching Netflix, my nightly wind down routine.” But it’s fantastic to have the energy to be pursuing things that you want to do with your life. A lot of that is cultivated.

It’s not just to say, “Oh well I’m genetically an energetic person.” I don’t think it’s that simple. I think we have to work to have that peak level of energy that can fuel us not to have to, if I’m being fully candid, kind of waste our lives spending part of the day in this semi-stupor of being tired and wiped out from your daily responsibilities, but rather have enough energy to pursue the things that you love. Sorry to get overly passionate here. But boy, if we can find a way to help people have enough energy to do everything that they want to do, then the world is theirs, and that’s an awesome feeling to be able to facilitate that.

HR:  Yeah, look, I really echo that passion. I don’t even want to try to match it right now. One thing that I often say is no one wants to sleep for sleep’s sake. We all want to sleep for living’s sake. It’s like all these things that we want to achieve in our lives, sleep lets you achieve them better and easier and faster. I think it’s just one of these things that we all were told a little bit when we were younger, but now the science is really backing us up, and large datasets are showing how crucial and important it is. So, we like to think about helping you sleep so you can achieve your dreams. All that stuff you want to do.

Like you said, you want to be able to play the piano. You want to be able to learn new things. You want to be an awesome interviewer. You want to be the best clinician that you can be. Those are your dreams, this is how you’re bringing yourself to the world, and better sleep, improving your sleep helps you do that in a much better way. I think, luckily, like we share the exact same passion. I think so much of the world does, too, if they just knew a little bit more, and we’ve designed something that we think will help people reach their potential. Really, really enable their potential and it’s thankfully easy to use, and we think the best thing that we’ve been able to put out into the world to help people achieve their dreams.

Episode Wrap Up

DrMR:  Well, I’ve got to thank you because I wasn’t expecting to have this type of experience. I was open and I was happy to be able to get a ring. But, obviously, I’ve sang praises for Oura Ring the entire episode here. I think my testimonial speaks for itself. If someone is kind of curious, where do I get one Oura ring?

HR:  So how do people start improving their sleep and improving their lives? It’s really simple. It’s Oura, ouraring.com. I would say, Mike, thanks a ton for trying out the product. I know a lot of people, everyone knows their sleep is important, but then once you have one and start tuning into the data and how you feel and your lifestyle choices, we hear exactly that we returned skeptics into believers. We’re just really lucky to be here and, honestly, thank people like you that are helping us spread the word. I think that’s the most important part.  We wouldn’t be able to exist without people like you, too. So, thanks for everything that you do. Thanks for actually bringing knowledge like you do to your audience every day, and to your patients in the clinic, too. So, really thank you for all of that.

DrMR:   Yeah, pleasure. I mean, people helping people, and we’re two people trying to help as many people as we can. So, yeah, thank you. I’m happy I’ve been able to bring this to our audience and please keep me in the loop. If there’s any new breakthroughs or publications, please keep me abreast.

HR:  I will. All right, thank you for your time, Mike. I appreciate it.

DrMR:   Thank you.