SEATTLE, WA—According to the Dalai Lama, sleep is the first form of meditation, one that human beings share with nearly all other living creatures, and one that is essential for normal mental, physical, and emotional functioning. Unfortunately, a vast and growing number of people do not obtain the sleep they need.

“Sleep disorders are extremely common among our patients, but the problems often go undetected because we do not ask about them,” said Richard Maurer, ND, at the annual meeting of the American Association of Naturopathic Physicians. The good news is that simple and relatively inexpensive nutritional and botanical supplements like magnesium, vitamin B12, Valerian and Chamomile can help the vast majority of people with insomnia return to healthier sleep patterns.

According to the National Sleep Foundation, nearly two-thirds of all US adults have never been asked by a physician how well they are sleeping, a troubling number given that more than half of all adults, when asked, will report some sort of sleep problem. “All doctors should be asking about this,” said Dr. Maurer, who practices naturopathic medicine in Portland, Maine. “Once you do start asking, you’d be surprised how common the problems are, and how much trouble they cause your patients.”

Over the last 100 years, the average American’s typical night’s sleep has been shrinking. At the beginning of the 1900s, most adults slept an average of 9 hours, or even more during the winter in rural areas. By 1970, it was down to 8 hours. In our current over-caffeinated world of extremely long work days, constant stress, and media overstimulation, many Americans consider themselves lucky if they regularly get 6 hours of uninterrupted sleep. While 6 hours may be adequate for a rare few people, the vast majority needs at least 7–8 hours. “Our physiology hasn’t really changed much since 1900, but our sleep patterns definitely have,” said Dr. Maurer.

Deep Sleep and REM Sleep

	Sleep cycles during an 8-hour night. Chart courtesy of Richard Maurer, ND.

A healthy night’s sleep is comprised of two basic types of sleep: slow-wave or “deep” sleep, and rapid-eye movement (REM) sleep. Physiologically, the two states are as different from each other as either is from ordinary waking consciousness.

Slow-wave sleep, also known as Stage 4 sleep, represents the smallest portion of a night’s sleep: it is the first phase to occur once someone falls asleep, and it comes on quickly. If uninterrupted, this phase usually lasts for roughly an hour. It is characterized by slow and regular heart and respiration rates.

“A lot of things go on physiologically during the deep slow-wave sleep phase,” said Dr. Maurer. The pituitary releases high levels of growth hormone that stimulates tissue growth and accelerates healing processes. There is also a lowering of total cholesterol, but an increase in HDL.

REM or Stage 1 sleep has a very different physiologic character: the heart and respiration rates become increasingly irregular, peripheral muscle tone is depressed, and brain activity increases markedly. This is the state in which dream activity occurs. “The brain is basically disengaging from motor regulation, but it is highly active. Brain metabolism may be increased by as much as 20% during the periods of REM sleep.”

In between Stage 4 (deep sleep) and Stage 1 (REM) are two other transitional stages characterized by relaxed muscle tone but no dream activity or rapid eye movement.

Typically, a sleeping person will spend the first hour after falling asleep in Stage 4 deep sleep, and then move through several repeating 90-minute cycles of REM followed by Stage 2 or 3 sleep. Generally, the depth of the non-REM phases tends to decrease over the course of the sleep period.

While a host of processes take place in the body during sleep, sleep is primarily for the benefit of the nervous system. “The primary symptoms of lack of sleep are much more mental than physical. The brain restores and repairs itself during sleep. It is not like the biceps or the heart really need to sleep. But the brain surely does.”

Sleep, Hormones, and Metabolism

During the course of a good night’s sleep, the body’s basal metabolic rate will decrease between 10% and 30%. Arterial pressure falls, pulse slows, vessels dilate, gastrointestinal activity increases, and a number of endocrine changes occur. The most important of these is the release of growth hormone.

Elevated growth hormone release during the first hour of sleep, that is, during non-REM deep sleep, is the very first sign of adolescence in a child. This hormone is not normally released during waking consciousness, but only at night. Though the primary release is during the deep sleep phase, the pituitary continues to secrete growth hormone throughout the sleep phases. Dr. Maurer stressed that people who chronically fail to get adequate sleep or have fractured, interrupted sleep, tend to have low growth hormone levels.

Prolactin is also released during sleep. There is a big prolactin surge in the early deep sleep phase, but it reaches its peak levels in the pre-dawn hours prior to waking. Though it occurs in men and in children, prolactin release is especially important for women of reproductive age. Sleep disruptions which interfere with the prolactin release can have a profound impact on fertility. “If a patient is having fertility problems, ask about her sleep patterns.”

Tumor necrosis factor (TNF) also increases 10-fold during a normal night’s sleep, and returns to baseline levels during waking hours. This cytokine is involved in the process of shifting physiology from REM to non-REM sleep states. Chronic sleep deprivation results in increases in daytime TNF levels. “The body is attempting to initiate deep sleep during the day. It is basically trying to compensate for what hasn’t happened at night.”

Paying Off the Sleep Debt

Repeated failure to obtain enough sleep has significant physiologic consequences and it is cumulative—just think back to your residency training years. People who typically sleep less than 6 hours on average have higher overall morbidity and all-cause mortality than those who get 6 hours or more. Fortunately, these consequences are largely reversible once the sleep debt has been paid off.

“Sleep debt is just that—a debt that must be paid off. Total sleep is marked by a body clock.” Fortunately, however, there is no interest rate on that debt. “If you take sleep-deprived people and put them in a sensory deprivation environment, they will sleep off more or less the exact amount of hours that were lost.”

Do naps count? Absolutely. A two-hour nap, more than half of which is passed in the deep sleep phase, will go a long way toward generating healthy growth hormone levels. Even 20 minutes can be a big help. However, if someone has a 38-hour sleep debt, they are not likely going to pay it off in short naps.

Alcohol and Caffeine

Many people end up living between caffeine surges early in the day followed by alcohol consumption to calm down in the evening. Neither substance is particularly good for entraining healthy sleep patterns, said Dr. Maurer. While it is true that some coffee drinkers can somehow manage to drink coffee in the evening and still fall asleep, most cannot. One of caffeine’s primary effects is to block the sleep-inducing effects of adenosine. Most people who drink coffee late in the afternoon have trouble sleeping that evening.

Further, there are chemical compounds within coffee that bind both calcium and magnesium, which can have adverse consequences on sleep. Magnesium deficiency often leads to increased muscle contractility. In many people this results in disruptive muscle spasms during sleep that completely fracture normal sleep architecture. “If a patient is a coffee drinker, make sure they are taking a 1:1 calcium to magnesium supplement, with additional magnesium at night before bed.”

Many people view alcohol as an aid for sleep, and it is true that an alcoholic drink will shorten sleep latency (the time it takes to fall asleep). However, alcohol tends to deprive the brain of adequate REM sleep. “They oscillate around Stage 2, and often pop awake several times in the night. Alcohol is really not good for sleep.”

Designing Healthy Sleep Routines

Though it is tempting for both patients and physicians to “solve” sleep problems pharmacologically, there are major downsides, not the least of which is very abnormal sleep architecture. Benzodiazepines do shorten sleep latency and lengthen sleep time, but they tend to put people into long periods of Stage 2 and 3 at the expense of the Stage 4 deep sleep. “You are essentially stopping the process in what would normally be a pass-through phase.” Benzodiazepines are also habit-forming for many people.

Newer non-benzodiazepine sleep medications interfere less with sleep architecture, so in that sense they are better than the older drugs. But great numbers of people have a hard time getting off these medications. “It is a very strong dependence, if not an out and out addiction.”

Before going the medication route, work with your patients to eliminate the behavioral barriers to better sleep. Dr. Maurer offered the following simple suggestions that can help many people with sleep problems:

• Time exercise so that it is more than 5 hours prior to going to bed: Vigorous workouts just before bedtime will usually result in long hours wide awake.
• Try as much as possible to go to sleep and wake up at the same time every day: Job contingencies, young children, social events and travel will, of course, make this difficult. But a regular sleep/wake routine can go a long way toward reducing sleep debt and improving sleep architecture, which will result in better overall health and higher daytime energy levels. One need not necessarily go to bed early, so long as one’s schedule allows adequate sleep, and the late-night schedule is more or less consistent. “What really messes people up is when they go to bed at 10 during the week, and then stay up until 2 or 3 am on weekends.”
• Save worries for daytime: Encourage patients to keep a pad by their bedsides, so they can write down all their worries, concerns, and to-do items before retiring for the night. This can help eliminate the worried, churning state of mind that keeps many people from falling asleep.
• Develop relaxing bedtime rituals: Hot baths, an uninterrupted period of relaxing music, a back-rub, a meditation, any form of relaxation can be of great help. It need not be formalized or rigid; rather it should be something relaxing that the person truly enjoys doing.
• Stop TV and online activity at least a half hour prior to bedtime: Television and internet activity seldom foster an easy transition into sleep. It is best to have at least a 30-minute interval between media exposure and bed.

Nutrients and Herbs for Sleep

Before writing out that Ambien prescription, consider how nutrients like vitamin B12, magnesium and 5-hydroxytryptophan phosphate might help your patients.

Vitamin B12: B12 (methylcobalamin) is commonly used in Japan as an aid to restoring normal sleep-wake rhythms. Management of sleep problems with B12 typically requires fairly high doses, on the order of 3–5 mg; the typical dose levels in multivitamin products are measured in micrograms, so this will not be adequate. B12 is a particularly good sleep aid for pregnant and lactating women, in whom herbal sleep formulas may be contraindicated.

Magnesium: This is one of the best nutrients for helping sleep, particularly in people who wake up repeatedly throughout the night. In one landmark 1976 study, 99% of 200 people treated with magnesium showed positive responses, including reduced sleep latency, longer stretches of uninterrupted sleep, and sense of refreshment on arising in the morning. Magnesium is also helpful for people with night terrors and nocturnal motor automatisms, both of which are associated with magnesium deficiency. “I tend to use magnesium citrate, and typically give between 400 and 800 mg per day in divided doses. Three doses of 250 mg, plus a multivitamin is usually adequate,” said Dr. Maurer. Be careful not to go too high, though, or you can induce loose stools, which will obviously not help patients sleep.

5-Hydroxytryptophan phosphate: This compound is a precursor to serotonin, and it helps induce a sense of satisfaction and relaxation in many people. It is available in 50 mg doses, and Dr. Maurer recommended 50 mg in the mid morning, another 50 mg in the afternoon, and 100 at night before bed. “Some patients get somewhat energized by it, so if that happens, have them take the night-time dose in the late afternoon.”

Melatonin: The scientific jury is still out on the value of supplemental melatonin for managing sleep problems. While studies based on subjective self-assessment have suggested melatonin can improve sleep as well as daytime alertness, there are no studies based on objective measurements that corroborate this. What is clear is that melatonin supplements are very well absorbed; a single tablet of a typical over-the-counter formulation can raise blood melatonin levels by a factor of 30. For short-term use, it can be helpful in restoring and normalizing circadian rhythms when they are disrupted, as in long-distance travel. It is useless in children, though, as they already have normally high melatonin levels compared with adults. “Giving melatonin to a child is like giving testosterone to a 16-year-old boy.”

Gamma-amino butyric acid (GABA): This amino acid is one of the brain’s primary inhibitory neurotransmitters. GABA neurons are located throughout the brain, and one of the primary effects of benzodiazepines is to activate GABA release. Many people experience a sense of calm and relaxation shortly after taking supplemental GABA. “There’s not a single citation on this in the medical literature, but I use it a lot. It works really well to help patients coast down into sleep,” said Dr. Maurer. He generally recommends 500 mg, twice per day, with one dose taken in the afternoon, and the second taken early in the evening.

Chromium: This mineral is proving increasingly helpful in management of diabetes, but it is not very sleep-friendly. The typical supplemental dose of 50–200 mcg sometimes causes insomnia, one of the main reasons diabetic patients drop out of chromium studies.

Valerian (Valeriana officinalis) and Chamomile (Matricaria recutitia): Extracts or teas of the root of Valerian, a flowering plant, are very common ingredients in botanical formulas intended to help sleep problems. Published data suggest Valerian can reduce sleep latency while improving sleep quality. It does not seem to reduce night awakenings. It does however produce beneficial increases in the duration of Stage 4 deep sleep. The typical dose of Valerian is 300–500 mg of a concentrated root extract prior to bedtime. Children between 6 and 12 years old can safely take half the adult dose.

Be aware, though, that people who are sensitive to herbs in general may find valerian to be stimulating rather than relaxing. For these patients, milder herbs like Chamomile or Skullcap (Scutellaria) may be better choices. Chamomile is a mild but reliable muscle relaxer, and many people find chamomile, taken as a tea or a tincture, to be a very soothing way to induce sleep.