Are You Practicing Sleep Hygiene? Some Insight Into A Good Nights' Sleep

Improving Sleep For Healthier Patients

Nov 17, 2017                      

Meredith Murray, ND
In today’s society where “being connected” and always “doing” is encouraged, getting inadequate sleep can sometimes be worn as a badge of honor. One-third of Americans report getting an insufficient amount of sleep^[1]. When I started to prioritize sleep in my own life, I was surprised at how other aspects of my life drastically improved—physically, mentally, and emotionally. When I shifted my clinical practice to really focusing on sleep as a crucial and non-negotiable first step that needs to be improved for my patients, I saw similar outcomes for them. After implementing simple interventions to improve sleep, issues previously difficult to treat seemed to lessen or resolve.
Although it is known that sleep is as necessary as food, water, and oxygen, the intricacies behind it are still mostly unknown. Sleep can be broken down into two systems: sleep-wake homeostasis and the circadian rhythm (or cycle). Sleep-wake homeostasis is the accumulation of sleep-inducing substances in the brain which alert the body that sleep is necessary after a period of time since the last period of sufficient sleep^[2]. The body’s circadian cycle is governed by the circadian clock, which is regulated by the suprachiasmatic nucleus in the hypothalamus and reacts to the body’s exposure to light and dark. While one is sleeping, there are two different cycles and stages: REM and Non-REM (NREM). NREM sleep makes up a majority of the portion of times sleeping and is mainly parasympathetic activity resulting in lowered heart rate, blood pressure, temperature, etc. REM sleep is often thought of as the “dream period”; however, a study released in 2017 showed that dreams can occur in NREM sleep as well^[3]. An author of a study that came out of University of Rochester in 2013 likened sleeping to a dishwasher cycle for the brain where it cleans itself of toxic metabolic byproducts^[4]. That alone should be a reason to encourage your patients to obtain the best sleep possible.
In daily practice, many of us face patients dealing with chronic diseases. The connection between chronic diseases and sleep health is astounding. The associated health consequences of sleep deprivation include hypertension, obesity, type 2 diabetes, depression, and anxiety.
It is now known that lack of adequate sleep is a risk factor for Type 2 diabetes, with length of sleep acting as a predictor of HbA1c. Sleep apnea, a common but often poorly diagnosed condition, has been associated with increased risk of cardiovascular disease. To screen for sleep apnea, it is important to ask patients about snoring and refer them to a sleep study if they have multiple risk factors. Obesity has been linked to sleep apnea as well as short sleep duration.
The other health consequence of sleep deprivation that needs to be discussed more regularly is drowsy driving. The effect of driving after 18 hours of wakefulness is equivalent to a blood alcohol content (BAC) of 0.05% and after 24 hours: a 0.10% BAC (0.08% is considered legally drunk^[5]).
Sleep deprivation can also affect a person on a genetic level. Gene expression is altered with insufficient sleep and influences inflammation, brain function, and neural plasticity. It also changes gene transcription responsible for regulating the circadian rhythm thus compounding the effects of sleep deprivation^[6],[7].
Sleep is something our body should do naturally, yet 50-70 million Americans suffer from some form of sleep disorder, resulting in the pharmaceutical industry for sleep aids being a multi-billion dollar industry^[8]. The use of sleep aids is 1 in 8 adults with reported ‘trouble sleeping’ and 1 in 6 with a diagnosed sleep disorder^[9]. These medications, such as the popular Ambien, are not without serious side effects. There are very effective and simple ways you can work with patients every day to improve their sleep and avoid taking these medications (or help them resolve the need for them).
Discussing Sleep Hygiene
At this point in time, it’s safe to say that a majority of the people seen in clinical practice are looking at some sort of screen the majority of the day. They are also likely working long hours and neglecting sleep in order to take care of other life responsibilities.
It is so incredibly important to discuss sleep hygiene patterns with patients. Most people will agree these are things they should do, but it is the responsibility of the practitioner to encourage these as if they were a prescription. These habits can positively affect the sleep-wake cycle and return patients to a normalized sleep pattern, resulting in adequate amounts of sleep. It is also important to counsel patients and their families on regularly reaching the recommended amount of sleep for optimal health (see table).

• Go to bed and wake up at the same time each day.
• Have a relaxing nighttime routine (that does not involve screens).
• Do not eat or drink within 2 hours of going to bed.
• Stop screens (phones, laptops, television) for 1-2 hours before bed.
• Keep bed for sleeping and sex only. Encourage patients to leave their bedroom if having delayed sleep latency.
• Try to avoid alcohol or smoking or using stimulants in the evening.
• Get regular exercise and have regular exposure to natural light.

 Nutrients and Herbs to Support Sleep
While trying to implement these sleep hygiene habits, herbs, nutrients, and nutritional supplements can offer support. Below are a few of the most common and popular ingredients in sleep products. They are often combined to work synergistically.

• Neurotransmitters and hormones:
  1. Melatonin – This is one of the most widely used natural sleep aids. Melatonin is a hormone of the serotonin cascade and naturally increases during nighttime/darkness when it is secreted by the pineal gland. Supplemental melatonin for sleep is non-addictive, has a short half-life, and helps people fall asleep. It is beneficial because it does not have a negative feedback to the natural production of endogenous melatonin. It is recommended to start with a small dose similar to what is naturally produced, 1-3 mg, and dose this 30-60 minutes before bed^[10].
  2. Tryptophan (and 5-HTP) – Tryptophan has shown to help improve sleepiness and decrease wakefulness. It has also been demonstrated that acute tryptophan depletion inhibits REM and prolonged REM sleep. Supplementing with tryptophan can modify serotonin levels, with serotonin being a precursor to melatonin^[11]. The average dose of tryptophan is 500 mg. Similarly, 5-HTP is used because it is the derivative of tryptophan and the direct precursor to serotonin and subsequently melatonin. 5-HTP is generally dose at 50-100 mg.
  3. L-theanine – This is a naturally occurring amino acid and has been shown to counteract the effects of caffeine, reduce stress response, and promote relaxation at a dose of 250 mg^[12].
• Herbs
  1. Magnolia – Traditionally used to treat anxiety and depression, it affects the GABA_A The compounds honokiol and magnolol have both been used successfully for insomnia. Honokiol can shorten sleep latency to NREM sleep. Magnolol can also have similar effects and has shown to increase the number of REM and NREM sleep cycles^[13].
  2. Valerian – This is a very familiar herb used as a sedative and relaxant. It also binds to GABA_A receptors and has a similar mechanism to benzodiazepines, though weaker. The volatile oils can also inhibit degradation of GABA. It is indicated for nervous excitement to improve quality of sleep and also has been shown to be successful in women with menopausal insomnia^[14]. It can be used throughout the day for anxiety as well as in a higher dose (300-500 mg dried root capsules) before bed. This may make people groggy upon waking, so use caution.
  3. Passionflower – A wonderful gentle herb for sleep issues, though best used as a synergist. It is another herb that binds to GABA_A It is indicated for people feeling overwhelmed with responsibilities that are affecting their ability to sleep. It also has an anti-spasmodic effect, which can be helpful for people who have muscle spasm as a result of anxiety. Dose of 200-500 mg; crude herb extract nightly.
  4. Adaptogen/stress support
     1. i) Utilizing herbs that are commonly known as adaptogens (such as Ashwagandha, Reishi and cordyceps) can be beneficial for addressing the HPA-Axis and subsequently sleep.

Overall, in addition to considering someone’s diet, activity level, and mental health, one should also always focus on ways to improve sleep. Sleep, often overlooked, is one of the pillars of health and well-being.

Recommended amount of sleep per age group^[15]

Age:
4-12 months	12-16 hours per 24 hours (including naps)
1-2 years	11-14 hours per 24 hours (including naps)
3-5 years	10-13 hours per 24 hours (including naps)
6-12 years	9-12 hours per 24 hours
13-18 years	8-10 hours per 24 hours
18+ years	7+ hours per night

^[1] CDC – Data and Statistics – Sleep and Sleep Disorders. Cdcgov. 2017. Available at: https://www.cdc.gov/sleep/data_statistics.html. Accessed July 30, 2017.
^[2] HOW SLEEP WORKS – THE TWO-PROCESS MODEL OF SLEEP REGULATION – HowSleepWorks. HowSleepWorks. 2017. Available at: https://www.howsleepworks.com/how_twoprocess.html. Accessed July 30, 2017.
^[3] Siclari F, Baird B, Perogamvros L et al. The neural correlates of dreaming. Nature Neuroscience. 2017;20(6):872-878. doi:10.1038/nn.4545.
^[4] Xie L, Kang H, Xu Q et al. Sleep Drives Metabolite Clearance from the Adult Brain. Science. 2013;342(6156):373-377. doi:10.1126/science.1241224.
^[5] Dawson D, Reid K. Fatigue, alcohol and performance impairment. Nature. 1997;388(6639):235-235. doi:10.1038/40775.
^[6] da Costa Souza A, Ribeiro S. Sleep Deprivation and Gene Expression. Sleep, Neuronal Plasticity and Brain Function. 2015:65-90. doi:10.1007/7854_2014_360.
^[7] Moller-Levet C, Archer S, Bucca G et al. Effects of insufficient sleep on circadian rhythmicity and expression amplitude of the human blood transcriptome. Proceedings of the National Academy of Sciences. 2013;110(12):E1132-E1141. doi:10.1073/pnas.1217154110.
^[8] Sleep disorders and sleep deprivation: an unmet public health problem. Choice Reviews Online. 2007;44(10):44-5682-44-5682. doi:10.5860/choice.44-5682.
^[9] Prescription Sleep Aid Use Among Adults: United States, 2005–2010 – Products – Data Briefs – Number 127 – August 2013. Cdcgov. 2017. Available at: https://www.cdc.gov/nchs/products/databriefs/db127.htm. Accessed July 30, 2017.
^[10] Ferracioli-Oda E, Qawasmi A, Bloch M. Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders. PLoS ONE. 2013;8(5):e63773. doi:10.1371/journal.pone.0063773.
^[11] Jenkins T, Nguyen J, Polglaze K, Bertrand P. Influence of Tryptophan and Serotonin on Mood and Cognition with a Possible Role of the Gut-Brain Axis. Nutrients. 2016;8(1):56. doi:10.3390/nu8010056.
^[12] Dodd F, Kennedy D, Riby L, Haskell-Ramsay C. A double-blind, placebo-controlled study evaluating the effects of caffeine and L-theanine both alone and in combination on cerebral blood flow, cognition and mood. Psychopharmacology. 2015;232(14):2563-2576. doi:10.1007/s00213-015-3895-0.
^[13] Shi Y, Dong J, Zhao J, Tang L, Zhang J. Herbal Insomnia Medications that Target GABAergic Systems: A Review of the Psychopharmacological Evidence. Current Neuropharmacology. 2014;12(3):289-302. doi:10.2174/1570159×11666131227001243.
^[14] Alschuler L. Sleep Well, Sleep Safely: An Exploration Of The Importance Of Sleep And Botanical Alternatives To Conventional Hypnotics. Gaia Professional Solutions; 2014:1-15.
^[15] Paruthi S, Brooks L, D’Ambrosio C et al. Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine. 2016;12(06):785-786. doi:10.5664/jcsm.5866.