Search Articles

clear search terms

Common Roots of Poor Sleep

We all know it: high-quality sleep is vital to every client’s healing. While the body appears from the outside to be still and inactive, sleep is a time when the body is quite busy. During the night, we restock our supply of hormones, process significant toxins, repair damaged tissue, generate vital white blood cells for immunity, eliminate the effects of stress, and process heavy emotions. Unfortunately we have an epidemic of poor sleep – from trouble falling asleep to often-interrupted sleep to actual insomnia. There are, however, several straightforward remedies you can offer your patients in this area. Whenever a new client is struggling with sleep, it is always a critical first priority to address in their healing journey.  Sleeping soundly will increase your patients’ motivation to make further lifestyle changes (e.g. when well rested, it is always easier to eat more healthily). And your help in making it happen will increase your credibility with them substantially.

We fall asleep largely due to the gifts of the pineal gland, a small ant-sized lobe near the middle of our skull in the interbrain.  Following our circadian rhythm, the pineal gland secretes a neurotransmitter and hormone called melatonin. Melatonin suppresses the activity of other neurotransmitters and helps to calm the brain (in part by countering the stress hormone cortisol). And as we become more drowsy, the brain slowly begins to turn off our voluntary skeletal muscle functions, so we don’t move around too much and try to act out our dreams or disrupt the body’s internal revitalization work (also why it’s so hard to move your limbs or shout out in response to a nightmare).

For ideal sleep, melatonin should be rising steadily and cortisol should be rock-bottom low at bedtime.  But there’s a catch: the pineal gland secretes melatonin largely in response to darkness.  And our evening cortisol levels are lowest in environments with low noise.   With our addictions to TV, video games, and email and social media in the evening, however, our choices can get in the way of  these natural pro-sleep chemical shifts. These devices mostly display full-spectrum light which can confuse the brain about whether it’s night-time or not. We also, unfortunately, tend to watch shows or view email that can be stressful (e.g. the evening news, a crime show, work email, or ever-longer to-do lists). Digesting a heavy meal eaten later in the evening may also impair sleep.

So the first thing we can offer our sleepless patients is support with their “sleep hygiene”.  You may be amazed at how often this is all they need in order to get better sleep. Help them to identify more calming, quieter evening activities (e.g. reading a book, taking a warm bath, going for a light stroll outdoors, playing with a pet, folding laundry). I recommend no email, TV, next-day-planning, or stressful conversations in the full hour (minimum!) prior to bedtime. If noise is an issue, recommend soft foam ear plugs or the white noise of a fan. It is also important for the bedroom not to be too hot, as this can disrupt sleep during the night. Herbal tea (e.g. lavender, chamomile, passionflower) can also help one to relax and set the tone for sleep.  Consider also recommending no food a full two to three hours before bed and no caffeinated food or drink after 2pm in the afternoon (e.g. tea, coffee, soda, chocolate, mate). Many patients are stunned to realize how much that mid-afternoon coffee or a later-evening, heavy meal prevents sound sleep.  Here is a helpful patient handout on the power of Sleep Hygiene.

There are definitely many cases, however, where pro-sleep behavior is simply not enough. For some clients, their brains simply aren’t able to make enough melatonin to ensure solid sleep all night long. Or there is a chemical imbalance preventing sufficient relaxation.

  • If they have trouble falling asleep, consider 300mcg or 1mg of melatonin taken 30 min. prior to bedtime (start with the lowest dose for several days before increasing, as this is often enough; taking too much will result in grogginess the next morning). This is safe and effective for short-term use..  Note that melatonin actually helps also to reduce blood pressure during the night too, a key respite for patients with hypertension.  Use of beta blocker medications or frequent use of NSAIDs may deplete melatonin and cause these sleep difficulties.  If it doesn’t help, however, then there may be a different imbalance at play.  Please read on…
  • If your client falls asleep fine but awakens in the middle of the night and cannot easily go back to sleep, their problem is likely an insufficient, steady supply of melatonin throughout the night. Giving them regular melatonin before bed probably will not help much. Instead, consider sustained release melatonin or 100-200mg of 5-HTP (5-hydroxytryptophan) before bed. The body makes melatonin from a neurotransmitter called serotonin. And  serotonin synthesis requires the amino acid tryptophan (which may be depleted in those with inadequate protein intake or those with ongoing infectious challenges). 5-HTP is a precursor to serotonin that, in a healthy body, can be converted to melatonin a few hours later. A steady flow of melatonin will help patients to sleep more deeply, soundly, and without interruption. Note: do not recommend  5-HTP to any client taking an SSRI or SNRI (or other serotonin-enhancing) antidepressant or sleep medications without their physician’s oversight (e.g. Zoloft, Trazadone, Wellbutrin, Ambien) as there is a risk of them developing serotonin sickness.
  • If a client has trouble with overnight “hot flashes” (especially if they are not perimenopausal/menopausal women), then the cause is usually abnormal cortisol rhythms.  If the flashes occur in the later hours of night (e.g. 2-4am), that is usually associated with high cortisol that is rising to meet the day early and aggressively (showing that the body has been primed to expect very stressful circumstances).  Significant, sustainable stress relief is key.  Night-time intake of calming adaptogenic herbs can often be helpful (e.g. holy basil, ashwagandha, magnolia, l-theanine e.g. Xymogen’s “CortiSolv”).   On the other hand if the hot flashes are earlier in the night, especially if they are associated with hunger, these might be due to low cortisol and thus low blood sugar overnight during the natural fasting window that occurs then (the same dynamic might also be the result of hyperinsulinemia).  The flash is due to a surge of epinephrine to force blood sugar back up to an acceptable level.  A bedtime snack that includes some carbohydrate and healthy fat might be helpful in the short-term (e.g apple with almond butter).
  • If a patient has full-fledged insomnia, a combination of melatonin and 5-HTP (yes, you can take both at the same time) is often quite helpful in combination with the sleep hygiene methods mentioned above – at least temporarily while you are helping them to reduce chronic stress and increase primary food satisfaction.
  • If a client has trouble getting stressful thoughts out of their minds at bedtime or cannot sleep due to pain, it is often because of an imbalance of excitatory and inhibitory neurotransmitters in the brain (specifically glutamate and GABA, respectively). They will likely benefit greatly from taking calming herbs one to two hours prior to bedtime. There are many blends available, and we recommend in particular an ashwaghanda and/or holy basil anchored formula. Our lives overall in modern times tend to create glutamate-dominant dynamics which can challenge the brain to calm down and allow sleep.  The conversion of glutamate to GABA especially requires as cofactors both magnesium (a common insufficiency, with stress increasing urinary loss) and Vitamin B6 (depleted by several types of drugs, especially oral, estrogen-containing medications/contraceptives). L-theanine can also help to increase GABA activity.
  • If a client has trouble sleeping when they have had an alcoholic beverage(s) in the evening, this is usually because alcohol interferes with GABA/Glutamate balance in the middle of the night.  Initially alcohol increases GABA (inhibitory) and blocks Glutamate (stimulatory).  Once the alcohol is metabolized and its effects wear off, however, there is a rebound effect that increases glutamate which wakes you up and makes sleep light and/or interrupted the rest of the night.  Taurine is an amino acid that acts in the brain as a calming neurotransmitter and may be taken at bedtime to ease and reduce the rebound effect.  Taurine increases GABA receptor binding and thus promotes an inhibitory state.  ~ 1000mg of taurine prior to bedtime may help to help reduce this interference.

Of course, sleep medications may be useful for acute situations when one is going through short-term trauma. Unfortunately, all of them work essentially as mild sedatives and are not addressing the root cause of any long-term sleep disturbance. They also come with a wide range of side effects that render them not ideal for long-term use – from dry mouth to stomach ache to a hangover-like fatigue the following day.  But it’s also important to make sure your patients understand that many of these medications can increase the risk of both cancer and death – even with just occasional usage.  If your clients wish to stop taking these medications, encourage them to do so slowly (weaning) to avoid any chemical backlash from neurotransmitter imbalance.

Without restful sleep, sustainable healing in the body is nearly impossible.  Plus it can be challenging for any of us to consider lifestyle change when we are exhausted, especially chronically, due to poor sleep.  Consistent, deep, sustained sleep is a seemingly simple, not-so-sexy but scientifically anchored imperative for getting well and staying well. Help your clients to be wildly satisfied by addressing poor sleep as an initial priority in your work together.

P.S.  If you are passionate about transforming healthcare through the power of functional medicine, we encourage you to learn more about our training program here.

To receive clinical tips like this one right to your inbox, click here to receive our weekly newsletter.

Like us on Facebook to stay connected to our rich (free!) content and be notified of our popular, monthly Facebook Lives.

Subscribe
Notify of
guest
61 Comments
Inline Feedbacks
View all comments

Phillip
Phillip

How to support a patient with a severe and debilitating insomnia who is on multiple drugs already and also uses many supplements. Dose mixing the medications with the supplements will have adverse affects?

SAFM Team
Reply to  Phillip

Indeed, some cases are so entrenched that it requires great patience and care to untangle the web of interdependence between the pharmaceutical drugs and possible supplements. Looking at a case of severe insomnia through the functional medicine lens requires asking questions what led to the insomnia in the first place – is it the primary symptom or a secondary issue due to a different problem that maybe got “fixed with a drug”? And also what is the current situation, are all the key basics in place – is their “sleep hygiene” impeccable?
Which drugs are indeed essential and which truly help? Unfortunately, so many people with chronic problems simply go from practitioner to practitioner and only add things to their list in search for the “magic pill”. Many things to consider and questions to ask.
Yes, great care should be taken in examining safety of added supplements if someone is already on any pharmaceutical drugs. These articles may be of interest with regard to sleeping aids:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634348/
https://www.sleepfoundation.org/sleep-aids/how-to-use-sleep-medications-safely

Kathryn Faraj
Kathryn Faraj

Magnesium is usually my first go-to with trouble sleeping. On that note, is there a magnesium you recommend?
I know there isn’t a hard and fast answer, and you have to dig deeper into the patient, but I am part of a busy practice and unfortunately don’t always have the time I would like to have for comprehensive functional medicine, but still want to be doing my best for my patient. Historically, I have felt like adding a magnesium supplement for sleep won’t do any harm. Looking for the best recommendation.

SAFM Team
Reply to  Kathryn Faraj

Yes, magnesium could benefit those whose issues with falling asleep and staying asleep are associated with glutamate to GABA conversion – magnesium assists this process. Also, in those who struggle with blood sugar regulation and insulin resistance – magnesium is necessary for carbohydrate metabolism. We have multiple posts on various forms of magnesium that you can find here:
https://schoolafm.com/ws_clinical_know/client-relief-magnesium-to-the-rescue/
https://schoolafm.com/ws_clinical_know/the-interconnectedness-between-alcohol-and-sleep/
https://schoolafm.com/ws_clinical_know/insomnia-relief-for-night-time-racing-mind/
In general, if you want to provide a simple magnesium support starting with magnesium glycinate or another amino acid chelate is a good choice and there are many good brands on the market to choose from.
You may also be interested in the “Sleep-myths-and-truths-for-practitioners” FB Live:
https://schoolafm.com/ws_clinical_know/sleep-myths-and-truths-for-practitioners/

CAROLINA CILIBERTO
CAROLINA CILIBERTO

For a patient with sleep issues, specially some trouble falling a sleep i suspect the root cause is insufficient serotonin due to several years of use of SSRI…being unable to recommend 5Htp for this client because of use of this medication, apart from sleep hygiene, what else could be helpful?

SAFM Team

Yes, sleep hygiene is an absolute must and prerequisite to sound sleep when working on deeper root causes! If you suspect the root cause to be insufficient serotonin, you definitely would want to address that by restoring the body’s ability to make it. Typically this would be a gut health intervention/support based on the specific client case.

LILY SMOLINSKI
LILY SMOLINSKI

Also, would taking straight GABA supplement help with calming the mind prior to sleep?

SAFM Team
Reply to  LILY SMOLINSKI

Yes, it could. There’s another post that speaks about GABA and sleep, that you may find helpful:
https://schoolafm.com/ws_clinical_know/video-clinical-tips-part-2-oral-progesterone-alternatives-for-gaba/

LILY SMOLINSKI
LILY SMOLINSKI

Hello,

In your experience, do these supplements work fairly quickly? AKA, would the clients reap rapid relief?

Thanks!

Bell Cochran
Bell Cochran

If 5 -HTP works well, how long should I take it ?

SAFM Team
Reply to  Bell Cochran

Thank you for your question, Bell. It depends on a person’s unique situation and if the root causes that created the need for 5-HTP have been resolved. Was it diet low in protein, or rather an issue with digestion and absorption, or was it a hormone imbalance. As you can see it’s not possible to give a black & white answer to this question.

Joanne
Joanne

Hi, I’m trying to order Metabolic Synergy from shop.designsforhealth.com, and they said I need a Practitioner Code. Is this something you can help with, or where else can I purchase Designs for Health’s Metabolic Synergy?
thanks

Lucy Bhalla
Lucy Bhalla

I have a 55-year-old female client, post menopause, no coffee or alcohol but had insomnia for a long time. She is very stressed. After working on the basics she now can fall asleep faster & wake up feeling somewhat rested but she is not getting a sound sleep. Her husband told her that she was tossing & turning in sleep. I guess she was wrestling with surges of epinephrine/norepinephrine during the night due to having too low of a cortisol level overnight. If that’s the case, is it appropriate to add 5-HTP? Thank you in advance!

SAFM Team
Reply to  Lucy Bhalla

In this case, you need to distinguish between these possibilities:
1) Insufficient melatonin production due to high stress (elevated nighttime cortisol prevents melatonin production), or
2) Insufficient melatonin production due to lack of cofactors/nutrients required for the synthesis (that’s where the 5-HTP would come in), or
3) Fully waking up (not just tossing and turning) due to surges of epinephrine/norepinephrine during the night due to having too low of a cortisol level (a small meal rich in complex carbohydrates and protein close to bedtime may help with that and then, of course, addressing the adrenal insufficiency).
From what you are describing it sounds that your stressed out client may be suffering from cortisol that’s too high at night time and that may be preventing adequate melatonin synthesis and sound sleep at night. This can be tested with a DUTCH Adrenal test. A good solution for that while you are working on bringing down the high cortisol via relaxation and breathing techniques and addressing the root causes of the stress, could be slow-release melatonin taken close to bedtime.