Sleepless in Portland

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1 Sleepless in Portland ~ Insomnia ~ A Naturopathic Approach Paula Cluney, ND Sarah Ackerly, ND, CPM Northern Sun Family Health Care 53 Main Street Topsham, Maine

2 Sleep disorders affect 30% of the population From Health Care Providers Most of my patients have trouble sleeping From the Centers for Disease Control and Prevention 70 million Americans suffer from chronic sleep problems From IMS Health Americans spent about $2 billion on prescription sleep drugs in

3 Symptoms of Insomnia * Difficulty Falling Asleep * Interrupted Sleep * Waking too Early * Poor Quality of Sleep * Light Sleep /Frequent waking * Not refreshed on waking

4 Sleep Problems Are A Symptom Of Many Other Health Concerns Mental health problems Substanceinduced Pain Low mood Medications Infections Stimulants e.g. Caffeine, Energy drinks Changes in thyroid function Anxiousness Excess energy 4 Drugs e.g., Cocaine,, Ritalin, Adderall

5 Sleep is a process that is controlled by the nervous system, neurotransmitters, and chemical messengers Sleep Regulation

6 Causes of Insomnia * Allergies, especially with respiratory symptoms * Hormonal changes like thyroid imbalances, pregnancy and menopause * Depression * Stress * Anxiety * Gastrointestinal problems like reflux

7 Causes of Insomnia * Sleep Apnea * Bladder problems * Chronic pain or low back pain * Lifestyle issues like shift work, napping and screen time * Neurological conditions like Parkinson s disease or RLS * Medications or stimulants including caffeine and alcohol

8 Recommended Sleep Age Amount of Sleep Newborns (0-3 months) hours/day Infants (4-11 months) hours/day Toddlers (1-2 years) hours/day Preschoolers (3-5 years) hours/day School Age Children (6-13 years) 9-11 hours/day Teenagers (14-17 years) 8-10 hours/day Young Adults (18-25 years) 7-9 hours/day Adults (26-64 years) 7-9 hours/day Older Adults (65+) 7-8 hours/day National Sleep Foundation

9 How Much Sleep Do We Need? * Rafael Santana, medical specialist at the Sleep Disorders Clinic, says that there is no fixed number of sleep hours * It depends on the age and needs of the body, for example an infant sleeps up to 16 hours a day, but for an adult 4-5 hours may be enough * What matters more is the quality of sleep

11 Deep versus Light Sleep * Deep Sleep or Slow- Wave- Sleep" heals the body and helps memory by taking pieces of a day's experiences, replaying them and strengthening them for better recollection * REM sleep heals the mind

12 Light & Deep Sleep * Normally, we start REM sleep - the sleep in which your brain is most active - about 90 minutes after we fall asleep and cycle every 90 minutes through the night 4-5 times * Deep sleep (SWS- slow wave sleep) generally promotes rest and restoration and is where your body s repair mechanism kicks in and the body releases growth hormone * Growth hormone is needed for kids to grow and adults to repair their bodies

13 Insomnia & Cancer * Tumors grow two to three times faster in laboratory animals with severe sleep dysfunctions, primarily due to disrupted melatonin production * Melatonin inhibits a wide range of cancer cell types, as well as triggering cancer cell apoptosis (self- destruction) * It also interferes with the new blood supply tumors required for their rapid growth (angiogenesis) * Poor sleep is also associated with an increased risk of insulin resistance and weight gain two additional factors that also play an important role in cancer development

14 Hormonal Causes of Insomnia * Progesterone has a sedative effect but reduces the deep sleep stage that occurs before REM sleep * Premenstrual insomnia- occurs from a rapid drop in progesterone * During ovulation and the luteal phase of our menstrual cycle, progesterone causes REM sleep to occur earlier in the sleep cycle, within 60 minutes

15 Hormonal Causes of Insomnia * Estrogen is more complicated than progesterone * It increases REM cycles, decreases the number of awakenings after sleep and increases total sleep time * Estrogen has an effect on the neurotransmitters: norepinephrine, serotonin and acetylcholine * It also affects sleep via its effect on cortisol * Cortisol has a diurnal variation- highest in am and lowest at night before bed

16 Women s Experience of Insomnia 57% of women experience insomnia at least a few nights per week 74% of stay at home moms report symptoms of insomnia Only 7% of women report receiving treatment for insomnia For many women, insomnia is linked to depression

17 Menopause * 50% of women have insomnia during menopause, due to changes in hormones, neurotransmitters or hot flashes * Lower estrogen decreases serotonin, leading to decreased melatonin and more pain because of lower levels of circulating endorphins * Estrogen itself may also have an antidepressant as well as a direct sleep effect

18 Insomnia Pregnancy & Postpartum * Sleep studies show a progressive worsening of sleep quality through pregnancy, with significant sleep problems after delivery, which may persist for at least the first 3 months post partum * A big drop in hormones postpartum affects neurotransmitters and sleep * An association between maternal depression and children's sleeping problems has been observed and depression improves when children sleep better

Adolescent Insomnia * 25% - 45% of adolescents in the US fail to get adequate sleep * Of these, 75% experience chronic insomnia * Sleep is critical to brain maturation, which is why it s so important

19 Adolescent Insomnia * 25% - 45% of adolescents in the US fail to get adequate sleep * Of these, 75% experience chronic insomnia * Sleep is critical to brain maturation, which is why it s so important in infants and adolescents * Mean sleep requirement for year olds is 9.2 hours * Up to 16% of adolescents experience DSPS, Delayed Sleep Phase Syndrome, where the internal circadian rhythm is out of synch with environmental time

20 Adolescent Insomnia * Process S is the drive to sleep that accumulates with increasing hours of wakefulness, changes during adolescence * This is associated with development of puberty * A 1 to 3 hour delay in melatonin secretion occurs, with girls experiencing an earlier onset of of this circadian delay one reason they go through menarche earlier than boys * A resistance to this sleep pressure allows adolescents to stay awake - up to 4 hours past scheduled bedtime

21 Alcohol & Sleep * Alcohol increases SWS, which may also increase vulnerability to certain sleep problems such as sleepwalking or nightmares * A review of scientific studies on the impact of drinking on nocturnal sleep has clarified that alcohol shortens the time it takes to fall asleep, increases deep sleep, reduces REM sleep and causes more sleep disruption * Increases in alpha- delta activity, which are associated with poor or unrefreshing sleep and daytime function, have also been observed in individuals with chronic pain conditions

22 Pain & Sleep * Women (58%) suffer from nighttime pain more than men (48%), according to a 1996 NSF Gallup Poll * In a more recent 2000 NSF Sleep in America poll, one in four women reported that pain or physical discomfort interrupted their sleep three nights a week or more * Pain conditions like migraines, tension headaches, rheumatic and arthritis conditions as well as heartburn are all more common among women

23 Shift Work * Changes in exposure to light and lost sleep caused by shift work may have biological or hormonal effects that are not yet entirely understood * One large study of women who worked night shifts over a 3- year period found a 60% greater risk for developing breast cancer

Sleep Apnea * Sleep apnea is a serious sleep disorder that is characterized by snoring, interrupted breathing during sleep and excessive daytime sleepiness *

24 Sleep Apnea * Sleep apnea is a serious sleep disorder that is characterized by snoring, interrupted breathing during sleep and excessive daytime sleepiness * An estimated 18 million Americans have sleep apnea including one in four women over 65 * While apnea is more common in men, it increases in women after age 50

25 Sleep Apnea * Being overweight is a risk factor for sleep apnea, the increase in abdominal fat during menopause may be one reason menopausal women are 3.5 times as likely to get this sleep disorder * Some attribute the prevalence to hormonal changes such as the decrease in progesterone to sleep apnea * Studies have found that sleep apnea is associated with atrial fibrillation and increased blood pressure, a risk for cardiovascular disease and stroke

26 Sleeping Pills * Research shows that sleeping pills don t work, but your brain is being tricked into thinking they do... * In one meta- analytic study, sleeping pills help people fall asleep approximately 10 minutes sooner an insignificant improvement * On average, sleeping pills increase total sleep 15 minutes * They result in poor, fragmented sleep - they also create amnesia, so upon waking, participants could not recall how poorly they d actually slept

27 Sleeping Pills * A study of 10,500 people who received drugs for poor sleep (hypnotics) had a 4.6 times higher risk of death compared to those prescribed no sleeping pills even in those who took fewer than 18 pills in a year * Sleeping pills linked to these risks included benzodiazepines (such as Temazepam), non- benzodiazepines (such as Ambien, Lunesta, and Sonata), barbiturates, and sedative antihistamines * The study showed increased risk for cancer and heart disease was 35% higher - British Medical Journal 2012

28 Risk of Sleeping Pills

29 Natural Approaches to Treatment

30 Insomnia Treatment Lifestyle Interventions And Behavioral Strategies Are The First Line Of Treatment For All Sleep Disorders

Naturopathic Medicine * Naturopathic medicine emphasizes prevention, treatment and optimal health by treating the whole person and educating patients to empower themselves to be part of their own

31 Naturopathic Medicine * Naturopathic medicine emphasizes prevention, treatment and optimal health by treating the whole person and educating patients to empower themselves to be part of their own health care * Naturopathy encourages the body s inherent self- healing through the use of therapeutic methods and substances * The practice of naturopathic medicine includes scientific, traditional and empirical methods

32 Naturopathic Modalities * Botanical medicines * Diet and Nutrition/Nutritional Supplements * Homeopathy * Lymphatic Massage * Lifestyle changes/counseling: - Stress Management - Detoxification - Weight loss - Sleep Hygiene * Constitutional Hydrotherapy

Healthy Sleep Tips * SQck to a Sleep Schedule and sleep in a cool, dark room * Develop relaxing bedqme rituals, like taking a bath with Epsom salts * Exercise daily results in less

33 Healthy Sleep Tips * SQck to a Sleep Schedule and sleep in a cool, dark room * Develop relaxing bedqme rituals, like taking a bath with Epsom salts * Exercise daily results in less anxiety, depression, and fewer hot flashes * Sleep on a comfortable mavress/pillows * Beware of interfering factors like alcohol and caffeine * Turn off all electronics 1-2 hours before bedqme

34 Nutritional Considerations * Restless Leg Syndrome- results in involuntary leg twitching or jerking movements during sleep that can occur every seconds. * Recent research indicates that iron or folate deficiency may be a risk factor * Magnesium Threonate- crosses the blood brain barrier to aid in neurological and nervous system relaxation for sleep - This form of magnesium is also effective for anxiety and pain relief

35 Weight Loss & Insomnia * Losing 5% of initial weight was associated with short- term improvements in sleep duration and sleep quality * There were favorable short- and long- term changes in mood * Weight loss also decreases incidence of sleep apnea

36 What Is Homeopathy & How It Can Help with Insomnia * Homeopathy is a natural healing system of medicine that originated in Europe over 200 years ago, and has been used in the U.S. since the early 19 th century * It is based on the philosophy that the body has an inherent wisdom to heal itself

Principles of Homeopathy * Homeopathic medicines work by stimulating this innate ability in the body and strengthening the entire system without harmful side effects

37 Principles of Homeopathy * Homeopathic medicines work by stimulating this innate ability in the body and strengthening the entire system without harmful side effects * Homeopathy is based on 3 principles: * Like cures like * Using the minimum dose * Individualized treatment - tailored for each person using the minimal dose required

38 Urinary Neurotransmitter Testing A New Way to Sleep Better

39 There are calming and stimulating neurotransmitters Calming Stimulating Serotonin GABA Taurine Glycine Epinephrine Norepinephrine Dopamine Glutamate Histamine PEA 39

40 40 Difficulty falling asleep, waking during the night, and waking too early results from imbalances in neurotransmitters

41 What causes neurotransmitter imbalances? Stress Emotional Physical Sickness Junk food Food additives Excess sugar Poor diet Toxins Pesticides Insecticides Mercury Genetics 41

42 Trends linked to poor sleep Elevated excitatory neurotransmitters Low calming neurotransmitters Hormone imbalances Sleep disturbances 42

43 Different patients, different imbalances, same problem can t sleep Neurotransmitter Patient 1 Patient 2 Patient 3 Patient 4 Epinephrine Norepinephrine Dopamine PEA Histamine Glutamate GABA Serotonin Glycine Cortisol Melatonin 43

44 Normal sleep treatment ignores individual differences: Trial and error Patient presents with poor sleep Patient prescribed sleep medication Try a new medication if sleep isn t improved 44

45 Is there a better way? Patient presents with poor sleep Identify unique imbalances Use therapy that addresses those imbalances Better sleep! 45

When a therapy targets the specific imbalance,

R.H., Vlosifescu, D., & Renshaw, P.F. (2003).

46 When a therapy targets the specific imbalance, the likelihood of symptom relief increases Low Serotonin Serotonin Support Serotonin Precursor Medication 2 Medication 1 46 Perlis, R.H., Vlosifescu, D., & Renshaw, P.F. (2003). Psychiatric Clinics of North America, 26(2),

47 47 What can be done to improve neurotransmitter levels? Healthy diet Exercise Toxin avoidance Direct support

48 Your diet provides the nutrients essential for optimal health Carbohydrates Fiber Fat Amino Acids Calcium Vitamins Protein Iron 48

49 Amino acids are the building blocks for neurotransmitters Your health care provider can use amino acids in his/her custom-tailored program to help relieve symptoms 49

50 A poor diet reduces your body s ability to make neurotransmitters Fast food Junk food Sugars 50 Processed food

51 Exercise & Insomnia One recent study found that overweight, post- menopausal women who exercise in the morning experience less difficulty falling asleep and better quality sleep than evening exercisers.

52 Exercise improves neurotransmitters Yoga Jogging Walking Raises the levels of many neurotransmitters Strength Training 52

53 Avoiding toxins Industrial cleaners Air pollution Water pollution Toxins stop communication in the nervous system Heavy metals Toxins kill brain cells containing neurotransmitters 53

54 54 Taking amino acids can increase neurotransmitter levels When you can t get enough from your diet to correct neurotransmitter imbalances.

55 Case Review 55

56 56 35 year old female Trouble falling asleep Trouble staying asleep Tired upon awakening in morning

57 Low calming neurotransmitter High excitatory neurotransmitters 57

58 58 Take- away Points Sleep is affected by many neurotransmitters and hormones. Imbalances can contribute to sleep problems. Identifying which neurotransmitter is out of balance is the first step in addressing sleep disturbances. Amino acids (the building blocks for neurotransmitters) are an effective approach for addressing sleep disturbances.

59 Ask your health care provider if neurotransmitter testing is right for you. 59

60 So You Can Sleep Like a Baby

61 And Wake Like This

62 And Not Like This

63 ~ Insomnia ~ A Naturopathic Approach For More Information: Call Northern Sun Family Health Care # Or visit us online at: Northernsunhealth.com

64 Bibliography * National Sleep Foundation.org * Harvard Healthy Sleep Website: Sleep and Disease. Healthysleep.med.harvard.edu * Adolescent Insomnia, Lisa Watson, ND. Naturopathic Doctor News and Review. March 23, * Hidden Causes of Insomnia, Bradley Bush, ND. Naturopathic Doctor News and Review. April 1, * Neurotransmitters and Sleep. sleepdex.org/neuro.htm * Neurotransmitters and Insomnia. Neuroscience/neurorelief.com * Hypnotics association with mortality or cancer: a matched cohort study. BMJ Open 2012;2. * Major sleep disorders among women: (women's health series) South Med J Aug; 106(8): doi: /SMJ. * Sleep in women.semin Neurol Sep;31(4): Womens Health 2008 Sep;17(7): * Sleep disorders and medical conditions in women. Proceedings of the Women & Sleep Workshop, National Sleep Foundation, Washington, DC, March 5-6, 2007.

Healthy Sleep Tips Along the Way!

Healthy Sleep Tips Along the Way! Women and Sleep What You Will Learn The Benefits and Importance of Sleep States and Stages of the Sleep Cycle Unique Physiology of Women s Sleep Common Disorders in Women that Affect Sleep Women s Role