Enter Sandman

by Lisa Schofield | March 20, 2019

Americans are more stressed than ever for a multitude of reasons, and stress disrupts the ability to relax, unwind, rest and sleep. Here’s how to help your patients chill and welcome a hesitant sandman.

“You’re getting sleepy.” Unfortunately, for an increasing number of people, that line uttered by every B-movie hypnotist is a seriously fervent wish. And as practitioners, you are likely dealing with more people of all ages and demographics complaining that they can’t seem to unwind and let it all go.

Both Serena Goldstein, ND and Robert Kachko, ND, LAc of InnerSource Health, practice in the “city that never sleeps,” which, noted Dr. Goldstein, is a spot-on nickname now more than ever. “In general, I notice people going to bed too late, waking up at least once or twice a night, and their inability to relax is not just at night, but also during the day. It may not be their main concern, but I’ve noticed it is something we still need to work on in varying degrees in more and more people,” she related.

Dr. Kachko, who also is the AANP (American Association of Naturopathic Physicians) president-elect, agreed. “I practice in New York City, and it seems that people are as stressed and unable to relax as they’ve ever been.” He added that he sees more and more adults reporting inability to fall asleep quickly and to remain asleep without interruptions.

Jacob Teitelbaum, MD, author of the Cures A-Z phone app observed that anxiety is especially prevalent in Millennials, many of whom are dealing with crushing student loan debt and trying to launch careers. Overall, he stated, “As the perfect storm for the human energy crisis continues to build, we are seeing a marked increase in insomnia and anxiety. It is critical to remember that the hypothalamic sleep center requires more energy for its size than any area in the body. So insomnia is a key symptom of energy depletion.”

One person’s inability to relax can be quite different than another’s. For example, Dr. Goldstein offered, in women, hormonal imbalances during peri-menopause tend to cause sleep issues, and in men, reduced testosterone production does the same thing. In all adults, however, blood sugar insufficiency (not just diabetes type II but pre-diabetes where there’s a gradual increase or elevated blood sugar markers) are a common cause of waking up in early morning.

But there are increasingly common factors that are responsible for adults who are missing quality sleep more frequently.

“Our bodies are operating in a world that is misaligned with our evolutionary needs,” opined Dr. Kachko. As a diurnal species, he explained, we are physiologically programmed to wake with the sun and sleep when night falls, which is what our ancestors did.

A 24/7 access to artificial light, plus full-plate schedules that don’t allow for easy unwinding at the right times, the biological clock/circadian rhythms are disrupted and not operating properly. “Add to this the fact that we regularly strain against our natural sleep drive (Tired? Have coffee.) and add in loads of beta brain wave-inducing blue light (that also blocks our ability to make the sleep hormone melatonin), and it is not a surprise that people struggle,” he commented.

Dr. Teitelbaum added that modern diets composed mostly of processed foods that are devoid of viable amounts of micronutrients and exposure to chemicals in the environment also contribute to insomnia.

According to the Centers for Disease Control and Prevention, up to 70 million Americans are believed to suffer from sleep disorders—and many turn to prescription medications to summon the sandman out of hiding. According to Statista, 31 percent of respondents in a survey asserted they regularly used sleeping medications as they reported difficulty falling asleep three to seven nights in a typical week. That’s a lot of sleeplessness going on. And more than likely, if you have a patient/client complaining of tossing and turning, and waking up in the wee hours of morning, he or she likely has tried and may still be using either an OTC (over-the-counter) sleep medication or a prescription.

While OTC and prescription sleep medications can provide short-term relief, dependence (and sometimes addiction) to sleeping pills is common, according to Dr. Kachko. “Taking them can help while addressing other core components of sleep hygiene but should never be the only solution,” he emphasized.

Side effects, as always, vary as well and sources encourage probing to find out what side effects the patient/client may be experiencing if he or she is taking sleeping pills. For example, Dr. Goldstein explained that individuals can experience adverse reactions such as overstimulation, or daytime sluggishness/fogginess. Some people may rely upon them so that eventually, they need higher doses to achieve the same lulling effect. “A high enough dose can depress breathing during sleep, potentially being fatal,” she warned. “Further, they can also cause serious withdrawal actions with ongoing use if stopped suddenly such as seizures or long-term anxiety, as they may alter our physiology.”

Dr. Teitelbaum added that even some over-the-counter sleeping pills like Benadryl (diphenhydramine) have been associated with increased risk of Alzheimer’s disease.

Treatment Concepts

Because causes of insomnia, tension and inability to relax/unwind are many and an individual can have multiple causes, taking the time to investigate and assess can help dramatically in recommending the most effective solutions.

For example, Dr. Goldstein said she asks such clients what time they’re going to bed, when they wake up, if they sleep fully throughout the night. She looks to identify any patterns, such as waking up at a certain time of night, the reason (i.e. if people get up to urinate, regardless of age, sometimes they drink liquids too late at night), if they have vivid dreams to discern if they are in deep sleep, or if there’s some sort of unresolved trauma, how long it takes them to fall asleep, and how they feel when they wake up (i.e. if they need coffee or another stimulant then this is a clue to their adrenal function). “I also ask about their daily routine, if there is one, as chances are if their life is chaotic or they feel like they’re always doing and going, their sleep will suffer.”

Her solution is to help them establish a natural rhythm by suggesting lifestyle strategies such as drinking water earlier in the day, finish eating two to three hours before bedtime, writing their tasks down for the next day, and limiting screen time, all which should help encourage quicker sleep onset. “An Epsom salt bath, magnesium supplements (usually the glycinate form), lavender pillow, and essential fatty acids are usually my other go-to’s to help them relax,” she added.

Dr. Teitelbaum first asks if the individual is “hangry”—or irritable when hungry; if so, he said, this is a signal of adrenal fatigue and will recommend EuroMedica’s Adrenaplex. He will also suggest avoiding sugar and increase salt especially if the client/patient has low blood pressure as well as increase protein intake.

Anxiety also causes inability to relax and interferes with sleep. It can be intense and the individual may not know he or she has it, so Dr. Teitelbaum then asks if the person has problems taking deep breaths, which usually indicates hyperventilation. This typically stems from burying feelings such as worry. These feelings then bubble to surface during periods of relative calm in the form of hyperventilation (“panic”) attacks. He also noted he would rule out hyperthyroidism, which is a less common cause. “An excellent anxiety herbal is EuroMedica’s Anxiocalm,” he said. “This unique fraction of echinacea has been shown to be as effective as Librium after six weeks of use.”

In addition, Dr. Teitelbaum pointed to cannabinoids, which can greatly help both sleep and anxiety. He likes EuroMedica’s hemp oils, which contain more than 60 cannabinoids that address insomnia, anxiety and pain. “I recommend three at a time (which contains 30 mg of CBD) for anxiety and up to five capsules for sleep. This works brilliantly for most people.

And finally, I like to strongly suggest a good high-potency multivitamin including magnesium (e.g. the Daily Energy Enfusion By Integrative Therapeutics or Clinical Essentials). This takes care of nutritional deficiencies that may be contributing.”

Dr. Kachko said he and his team always begin with a “very thorough intake,” which focuses on the person’s sleep history, current sleep hygiene, stress/trauma history, dietary/fluid intake. They may also test hormone levels (cortisol, neurotransmitter, melatonin). “It’s helpful when people come in having done a sleep study, as this allows us to be more precise early on,” he related. “Similarly, if a person has sleep apnea and needs a CPAP machine or other oral device, they simply will need that support before they can get better.”

Every patient at InnerSource Health, he stated, is educated about essentials of sleep hygiene and the concepts of sleep debt/biological clock.

Stimulants: Avoid stimulants after dinner or stimulating activity (mental or physical) two hours before bed. Don’t consume caffeine after about 1 p.m.

Power Down: Turn off devices that emit blue light, such as TVs, smartphones and tablets as this light interferes with the production of melatonin—the sleep-inducing hormone.

Black Out: Try to keep your sleep environment as dark as possible, as any light from the outside interferes with our circadian rhythms. Whenever this is not possible, sleeping masks may be recommended.

Unwind and Let Go: Choose something relaxing (a warm bath, light reading) to enjoy before going to bed; it will promote relaxation, setting the stage for quicker sleep onset.

Cool Down: Studies show that a slightly cooler room can be helpful in achieving restful sleep. Suggest setting the temperature between 67-69 degrees Fahrenheit.

“For some, making these changes is sufficient,” Dr. Kachko asserted. “When that is not the case, a combination of carefully selected calming nutrients/herbs before bed and acupuncture tends to do the trick. Most patients are also given guided meditations, recorded specifically for them and their situation during acupuncture sessions, to listen to before bed and in the morning. If there are issues with blood sugar or cortisol abnormalities throughout the night, we’ll work to repair those things as well.”

A novel approach to helping people define why they are sleeping poorly is Sleep & Me, an application that helps users discover the right sleep habits for them, according to founder Ben Coleman. By answering several questions each time they use the application, they will receive insights about their tendencies – eg., “I sleep for 18 percent longer when I work out in the morning” and can evaluate new habits, “the new pillow actually decreases my REM sleep.”

Coleman explained that “there is a great deal of science behind the various changes we may suggest as we learn more about our users’ needs but our ‘main ingredient’ is the scientific method itself: we allow users to apply real statistical scrutiny to their sleep to identify solutions hidden in plain sight.”

Coleman said he developed the Sleep & Me app to create a simple system that sets users on a clear path to better sleep. As they interact with the app each day, they learn more about their needs, and can make small adjustments to fill those needs, especially with the help of their natural practitioner. “It’s designed to give direction to those who don’t necessarily know where to start, or make following the process easier to those who are struggling to keep up,” he said.

Natural Solutions

Patients/clients who want natural solutions to help lull them into restful slumber have several strong choices that you can recommend.

Texas-based LifeSeasons offers three products that help ease anxiety and promote relaxation. “Adrenal-T is a foundational product to reduce cortisol levels and relieve stress, described Robin Rogosin, vice president, product development. It features adaptogens rhodiola, holy basil, schisandra, ashwagandha, plus B vitamins, antioxidant-rich yerba mate and goji berry, along with the nervine avena (oats). Adaptogens have been shown in several studies to promote a feeling of well-being, lessen fatigue, and some may improve cognition.

Anxie-T promotes relaxation by nourishing the brain and nervous system with L-theanine, GABA (gamma-amino butyric acid), theobromine, magnesium, kava kava, which has anxiolytic and muscle-relaxant properties, as well as the adaptogen ashwagandha.

Rogosin said that LifeSeasons’ Rest-ZZZ is “specifically effective for sleep, and good sleep is required in order to maintain good health.” It includes GABA, a calming neurochemical, the relaxation-inducing herbs valerian root, passionflower, chamomile, hawthorn berry and lemon balm, along with melatonin. “The result is restful and restorative sleep without morning grogginess,” she explained.

For clients/patients with periodic or ongoing sleeplessness, Rogosin recommends two capsules of LifeSeasons Rest-ZZZ in the evening 20 to 30 minutes before bedtime. “The suggested dosage is simply a guideline, and some people take one capsule (if they are especially small statured, or have a sensitive constitution), or three capsules (if they have a larger build),” she explained. Rogosin recommends Adrenal-T as a daily supplement for clients/patients with ongoing stress, and Anxie-T periodically, as needed. Some individuals have certain times of day when they feel anxious, such as commuting on the highway, public speaking, attending meetings, or social situations, which, she noted, “are good times to use Anxie-T.”

Texas-based Natural Vitality’s CALM contains magnesium (citrate and glycinate) along with GABA, L-theanine and melatonin to provide sleep support, according to Susan Piergeorge, MS, RDN, nutrition education manager. Natural Vitality conducted a survey of its customers and one of the most common reasons for taking CALM was for sleep, she related.

“As magnesium plays a role in nerve function, maintaining adequate levels is also of importance in relation to neurotransmitters such as GABA. GABA is an inhibitory neurotransmitter associated with calming nerve activity in the brain,” she explained. “Magnesium is an ally of GABA production. L-theanine is an amino acid found primarily in green tea. Research suggests it promotes slower alpha brainwaves which may be responsible for the calming effect attributed to L-theanine ingestion.”

Many of these supplemental solutions are effective at tackling short-term solutions (more immediate results) as well as long-term support; the two-pronged approach will likely be what you recommend, along with specific lifestyle adjustments relevant to the individual.

It also may take some time to find the causes of the person’s inability to achieve restful sleep and anxiety, so it may be trial and error, which isn’t unusual. Keep in mind, too, according to Harvard Medical School’s Healthbeat newsletter, “nearly half of insomnia cases stem from psychological or emotional issues. Stressful events, mild depression, or an anxiety disorder can make falling asleep and staying asleep difficult. Ideally, once the underlying cause is treated, the insomnia improves.”

Healthy Take Aways:

• The hypothalamic sleep center requires more energy for its size than any area in the body.
• Up to 70 million Americans are believed to suffer from sleep disorders.
• Studies show that a slightly cooler room can be helpful in achieving restful sleep.
• As magnesium plays a role in nerve function, maintaining adequate levels is also of importance in relation to neurotransmitters such as GABA.
• Research suggests L-theanine promotes slower alpha brainwaves which may be responsible for the calming effect.