Sleep
There are few universal experiences quite like sleep. When it's done right, it can be enjoyable, rejuvenating, and healing. Adequate, appropriate sleep can help athletes recover from tough exercises. It can help students set important information in their memories. When done poorly, it can be grueling, tedious, and even...nightmarish. According to the CDC and the Sleep Foundation, most adults need between 7 and 9 hours of sleep, but across the United States, about 1/3 of adults get 7 hours or less. Poor sleep can lead to more frequent acute illnesses like viral infections, chronic diseases like cardiovascular disease, and mental diseases like depression.
In a perfect world, you would avoid computer or TV light 60 minutes before bed while performing a wind-down routine like meditation. Between 9 and 10pm, you would retire to your bedroom which is cool, dark, and quiet. Your comfortable bed would only be used for sleep and be at least 5 feet distant from any electronic device. Your brain would enter 4 to 5 90-minute sleep cycles of light sleep, moderate sleep, deep sleep, and REM sleep (that's rapid eye movement). After 7-9 hours, you would wake up and take in the morning sun for 15 minutes to help reset your circadian rhythm. But perfect is not always easy, is it?
We typically break up sleep issues into 3 different conditions: insomnia, sleep apnea, and restless leg syndrome. Today I'll be talking mostly about insomnia. Insomnia is the inability to sleep. It can be broken up into 3 main types based on when the issues occur: sleep-onset (difficulty falling asleep), sleep-maintenance (difficulty staying asleep), and early-morning-awakening (waking up too early).
hoops, but that can actually lead to less sleep (or I should say, less quality sleep). Chemicals such as alcohol, 1st generation antihistamines (like diphenhydramine which is Benadryl), and even prescription medications that are meant to help people sleep can actually prevent the brain from entering deeper, more refreshing levels of sleep. But there may be some things we can do to assist in sleep even if we can't have the ideal night.
For insomnia, I'd like to cover some behavioral recommendations before getting into supplements and herbs. First, try not to look at the clock when you're trying to go to sleep. Worry is the enemy of sleep, and you drive up your worry by paying attention to how long you've been awake or thinking about how much time you have before you need to wake up. If you find yourself watching the clock, it could be that you're spending too much time lying awake in bed trying to go to sleep. If you find yourself unable to go to sleep, get up and out of the bedroom. Do something quiet and relaxing like reading, knitting, or listening to peaceful music. Do not fall asleep on the couch or chair, but go directly to bed once you start feeling sleepy. After about 3 days, your body will start to get into the habit of being sleepy when you get to bed. Plus, you'll naturally be tired from being up for some of the time in the previous nights. On the same note, don't use your bed for non-sleep related activities like reading, watching TV, or studying. This helps your subconscious know that the bed is for sleeping.
Sleep restriction therapy (SRT) is a subset of cognitive behavioral therapy for insomnia (CBTI) that has shown physical improvements for postmenopausal women. SRT is a way to improve the percentage of time asleep compared to the time in bed. For example, if someone combating insomnia sleeps 6 out of the 8 hours they are in bed, the percent of time they're sleeping is 75%. Preferably, this should be closer to 85-90%. With SRT, the patient only gives themselves enough time to sleep for the amount of hours they're actually sleeping. As they feel more tired earlier in the evening, they give themselves a little more time in bed with the goal of keeping the percentage up. Although not as effective at treating some of the cognitive issues surrounding insomnia compared to CBTI, SRT did show an improvement in sleep quality when compared to sleep hygiene education alone.
Exercise may also be beneficial for some patients. According to a systemic review of 3 meta analyses of trials conducted on sleep, evidence is not hard enough to recommend for every patient. This may be due to the wide variety of exercises available and the sensitive timing involved. For example, if I exercise in the late afternoon or early evening, my heart rate goes up and engages my endocrine system to release hormones needed for fight or flight (or work hard and work fast). By the time I'm ready for bed, these hormones have come down causing a natural sleepiness. However, if the exercise happens too late in the day, those fight or flight hormones could potentially keep me awake.
Finally, it's important to get some sunlight exposure. I found a curious little trial that demonstrates this necessity in a round-about way. 32 participants with primary insomnia were exposed to bright light either in the morning or in the evening to see how much their circadian rhythm would be thrown off. The surprising result came in the varied sleep results of those exposed to light in the evening. Sleep time shifts were more intense in those who had least daytime light exposure. Those who were exposed to daylight the most during the day were less affected by the evening light exposure. Hypothetically, the daylight exposure during the day helps to keep the circadian rhythm in tact while those getting less light experience more sleep-time shifting. This shift could potentially influence insomnia, so I recommend getting out into the sunlight for at least some time everyday.
It may also be beneficial to review my podcast on stress. Reducing stress near bedtime can help the mind and body relax during the process of going to sleep. For example, take time to meditate, listen to calming music, use essential oils meant for relaxation, or get a massage.
Traditional Chinese Medicine has beneficial interventions as well. A study looking at acupuncture demonstrates efficacy against sham treatment. Each participant received a 30-minute treatment 3 times a week for 4 weeks. The insomnia severity instrument was used among other measures before intervention, and in 2 week intervals 5 more times across the study. This showed that sleep efficacy lasted at least a month after treatment.
Now that I've covered some of the activities people can do to help them sleep, I'd like to move on to the products people use.
First on the list is magnesium. It is used in over 300 processes in the body, and found in every organ in the body. It's used to help some neurochemicals mind to their receptors. A study involving 43 elderly adults took magnesium oxide 414mg (250mg elemental Mg) twice a day in a double-blind, randomized, placebo controlled, cross-over trial. Participants experienced better quality sleep as measured by the insomia severity index (ISI). They also got more sleep which improved their sleep efficiency compared to placebo. Improved levels of renin, melatonin, and cortisol were also observed. Surprisingly, serum magnesium was not as dramatically changed as one might think from taking a magnesium supplement. One explanation is that magnesium is found more in the tissues of the body rather than the blood. Also, magnesium oxide is not a very easily absorbed form of magnesium. It causes diarrhea more easily than chelated forms like magnesium glycinate.
Another study looked at l-tryptophan. This is another placebo-controlled, double-blind crossover study. Participants were split in two groups based on alleles suspected to influence tryptophan. Each group took 1 gram of l-tryptophan or matching placebo and then were crossed over to the other. Although the allele did influence subjective measures of restfulness and night wakings, objective measures of sleep efficiency and time to waking after going to sleep were comparable between the two groups. For falling asleep and staying asleep longer, tryptophan looks like a good option regardless of genetics.
Chamomile can also be beneficial. Most people think of the calming effects of chamomile tea, but t here was a study that compared an oral dose of chamomile extract 200mg compared to a wheat flour placebo in a single-blind block randomized controlled trial conducted in a nursing home. The dose was taken twice a day for 28 days. Although the two groups scored equally poorly on a sleep questionnaire at the beginning of the trial and 2 weeks in, the chamomile arm had significant improvements in all 18 measured outcomes of the questionnaire compared to the relatively stable placebo group by the end of the 28 days. Subjects were questioned again 2 weeks later and found sustained improvement. I should note that chamomile can cause allergy symptoms and can also cause mild blood thinning effects and should be taken with caution.
I am excited to discuss a trial that ran a combination of 3 herbs against a common sleep drug. Hops 30mg, passion flower 80mg, and valerian 300mg were combined into one tablet and given to participants for 14 days. The control group took zolpidem 10mg. This was a double-blind, randomized controlled trial. Subjects were enrolled if they suffered insomnia which meant <6 hours of sleep nightly. Sleep journals were kept for a week before intervention and through the study, and they were evaluated for average sleep latency, total sleep duration, and number of nightly awakenings. A few other sleep quality tools were used as well. Participants in both arms were evaluated at baseline, 1 week through, and at the end of the 2 week intervention. Although both groups reached significant improvement measures on sleep, there were no significant differences between groups. Basically, the combination herbal product performed equally well to zolpidem. Similar adverse effects were found in both groups which were all mild.
Ayurvedic medicine can also shed some light on insomnia. This field of study is fascinating to me because of its influence on personality. For more details, you can find my post on Ayurvedic medicine and the 3 doshas. Basically, there are three types of energies: vata, pitta, and kapha which is basically quick, moderate, and slow. In a cross-sectional study of 995 participants, self-assessed sleep quality was compared to tridosha questionnaire scores. The study found that higher vata scores had a strong correlation to difficulty falling asleep and not feeling rested in the morning. On the other hand, high kapha scores were correlated with longer day-time napping. The study's goal was to support the ancient predictive method with modern results. The trouble with this predictive model in western medical philosophy is that each person would be treated differently based on their dosha. One person's insomnia may not be treated the same as another because their dosha balance is different. However, there are some overarching themes that can be applied. For example, insomnia seems to be associated with overbearing vata, so treatments would be aligned with balancing vata out.
That's all the time I have for today. Let's quickly review what we've learned. For insomnia, practice good sleep hygiene. Focus on optimizing your sleep percentage - that's how long you're asleep versus how long you're in bed. Lavender essential oil and calming music may help calm the mind and help with sleep. Get some regular exercise and morning sunlight exposure. Melatonin, magnesium, l-theanine, l-tryptophan, chamomile, hops, passion flower, and valerian have all shown some benefit in helping with sleep with fewer side effects compared to standard sleep aids. It may also be beneficial to evaluate your personal dosha and find ways to balance your energies by reducing vata. Acupuncture by a qualified and skilled acupuncturist can help, too.
Thank you for joining me today. If you have something to add to the conversation around sleep, I would love to hear from you. Please reach out to me via email at integratedpharmacist@gmail.com. You can also help the podcast grow by leaving a positive rating and review. Thanks again for listening and we'll see you next time on the integrated pharmacist podcast.
References:
Irwin MR. Why sleep is important for health: a psychoneuroimmunology perspective. Annu Rev Psychol. 2015 Jan 3;66:143-72. doi: 10.1146/annurev-psych-010213-115205. Epub 2014 Jul 21. PMID: 25061767; PMCID: PMC4961463.
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