Poor sleep is an insanely common problem amongst us Americans. The consequences of even a single bad night of sleep are pretty dramatic, impacting our memory, energy levels, motivation, and more. Missing a full night’s sleep a few times weekly over the course of months can cause even more severe symptoms, changing the way our hormones are secreted, increasing stress levels, and further reducing sleep.
Today, we break the chain. We present a comprehensive guide to managing insomnia in a holistic manner.
For me, sleep management is foundational to optimizing your health. Along with diet, exercise, and stress management, sleep is a pillar of the bottom tier of our wellness pyramid:
Many problems can be resolved with proper lifestyle management, and sleep is a core part of that. Good sleep is that important.
In this article, we’ll help you understand different types of insomnia, talk about healthy things to help with sleep, and discuss supplements to support healthy sleep.
First, A Warning
What follows will seem like a big “easier said than done” article. These strategies I lay forth have always been incorporated into my 1-on-1 approach to helping people sleep. When face-to-face with customers, most will say, “yeah yeah” and ask for something to take. But something, “natural”, mind you. I retort in my half-professional manner, “What’s more natural than doing the work?” Because we have so many comedians, I often hear, “Well, not that natural!”
There is nothing more natural than proper sleep hygiene to restore a restful night’s sleep. There is no agent better than simply doing the work that needs to be done to restore your sleep. Looking for a pill (herbal or from “Big Pharma”) instead of taking a holistic approach first is a reflex we want to avoid, and we don’t want to kid ourselves into thinking using valerian for sleep is moral high ground to Ambien.
Before you begin on your journey to better sleep, REALLY evaluate your goals. Do you want to take something and all your troubles melt away? Or are you willing to do the work to solve the problem, if possible? I know you can do the work, and I’m confident that doing so will provide much better outcomes than the shortcuts some supplements promise.
Why Can’t I Sleep?
There are a billion reasons, it seems, that we can’t sleep well at night. While the current political climate, the upcoming holidays, and the rising price of cable all have a toll, anxiety is just a small part of the big picture. We can lump most of our troubles into a few general categories:
- Breathing Difficulties/Sleep Apnea
- Cramping/Twitching/Restless Leg Syndrome
- Bladder Problems
- Hormonal Issues
- Comfort (Of course!)
They’ve got a name for everything. Some of us can’t fall asleep – onset insomnia. Some of us have difficulty staying asleep – maintenance insomnia. If we have a long-term inability to sleep regularly, that’s chronic insomnia. This bar is kinda low; if you don’t sleep well 3 nights a week for 3 months or longer, you’re in the “chronic” category. Acute insomnia is much more short-term, and typically is associated with life’s surprises and stresses and resolves on its own.
Properly identifying and managing the cause(s) of your insomnia is about 75% of the battle for most of us. For others, there are no conditions that are directly causing insomnia. Instead, it’s a messed up sleep cycle due to all our modern “comforts.” Let’s rehash the cycles and see how we can get back in sync.
The Rhythm of Life
Most people who talk about sleep talk about the sleep cycle – the 5 stages of sleep that range from REM (rapid eye movement) sleep to deep sleep and back again. We don’t want to bore you.
Instead, let’s focus on the bigger picture. The circadian rhythm, or the 24-hour cycle of waking and sleep, that all living things experience.
There are two main hormones that are responsible for us getting tired, falling asleep, then waking and providing energy through the day: melatonin and cortisol.
Here’s a graphic showing how the two “dance” throughout a period:
Dark areas are night. Yellow are the day. Color coding for the win!
At night, melatonin starts to rise as the sun sets. It peaks in the middle of the night then falls when daytime starts coming. Cortisol then revs up to peak early morning, then falls off a cliff mid-day (2-3 pm). So, organize your coworkers to get mandatory naps at work, because that’s just evolution and your employer should support that.
These hormones respond to cues. Not subtle cues, but the flaming ball of gas 93 million miles away. Sunlight (or lack thereof) is what tells our body to secrete these hormones and when.
So, when you take humans who have evolved to involuntarily follow these cues, then introduce electricity – bright white unnatural light, colorful screens, and now even bright computers that we can lay down and use in bed – havoc will follow.
What has happened, for many of us, is a shift in when these hormones are released and for how long. Melatonin secretes WAY after sundown. Our sleep starts later, so our cortisol doesn’t peak when it’s supposed to. Our sleep/wake period shrinks:
Our sleep/wake cycles are essentially pushed back because we stay up late in brightly lit rooms staring at intense, bright screens. Then, when the sun peeks out, we try to ignore it by blacking out our windows and lay in bed longer than our human bodies want. Our melatonin falls off hours after we wake; our bodies think we should be sleeping for hours past when we should. We’re creating a state of jet lag without the benefit of cross-continental travel.
The Stepwise Process to Restore Your Sleep
Here’s the quick and dirty:
- Identify your insomnia
- Address underlying problems
- Practice Proper sleep hygiene
- Take steps to correct or optimize your sleep/wake cycle
- Take stuff, including supplements and medications
Identifying Your Insomnia
To get somewhere, we first must figure out where we are. Do you have difficulty falling asleep or staying asleep? How often does this happen a week? For how long has this happened — weeks? months? years?
Most importantly, are you taking anything currently to assist with your sleep, and if so, has it helped?
Addressing these in reverse order sounds reasonable in my mind:
- If you are using something to help you sleep but still have chronic insomnia, it’s probably a wise move to drop whatever you are taking and start fresh (with a Doctor’s approval, if medical, of course). Too often will people have rather complex regimens yet still complain of insomnia. If one thing isn’t working and the dose is maxed out, drop it before you add more.
- If you haven’t given the strategies we’ll lay out here a fair shake, it may be best to do so unaided by over-the-counter meds or supplements. Rip the Band-Aid off. Go big or go home.
Difficulty Falling Asleep
This is usually something easier to deal with than waking up in the middle of the night. Most of the time this is due to stress or anxiety preventing you from relaxing enough to fall asleep. Sometimes medications and supplements can have a stimulating effect, so chat with us to see if maybe moving your dosing schedule around is a good move. Poor sleep hygiene, or the habits around the end of day/preparation for sleep, can also cause onset insomnia.
Waking Up In The Middle Of The Night
Maintenance insomnia, again, is waking up in the middle of the night. The best seed I can plant in your minds is this: if you are waking up in the middle of the night, there are often medical reasons why and a sleep study is your best way to figure out (or eliminate) possible causes. I highly recommend our strategies to get your clock set back correctly, but sometimes people wake up in the middle of the night because of problems they didn’t know they have. This pearl comes from work early in my pharmacy practice ownership, working closely with a sleep specialist MD.
The second step, then, is to address potential medical causes of insomnia.
Strategies for Better Sleep
Let’s look at each one of those causes of insomnia from before and talk about some ways to address those problems that you may have not yet heard.
Anxiety or Stress
Stress management is difficult. The best answer to this is meditation and mindfulness, which we owe an article to in the near future. Anxiety is the gap between what is real and what we are projecting/dreaming/imagining to be. The bigger the gap, the stronger the anxiety. Mindfulness and meditation retrain your brain to focus on the here and now.
I read a lot of business books, mostly because I’m bad at business and need help. One book that has revolutionized not only business, but even psychology, is Getting Things Done. In it, David Allen presents a unique take on stress: Stress today comes from all the junk swishing around in our brains, which is the worst possible place for all the todos, lists, and plans we make. He suggests if we had a trusted system OUTSIDE our brain to store the data, our brain will be free of what he calls “unclosed loops”.
How many times have you been in bed and a thought pops in? “Oh, I have to call Sally back about…” If we try to keep this thought in our brain to recall later – at a more appropriate time, say near a phone and not in bed – this “unclosed loop”, though no longer top of mind, will use our brains processing power somewhere in our subconscious.
For the purpose of this article, keeping a pad of paper and pen near your bed will help you sleep. Not because of the magic energy of these items or the smell of stationery being calming, but because you can use it to jot down these thoughts as they bubble up. Your brain is FINALLY getting some quiet – some time to process all the stimuli coming at you. As you build up some space, it will want to let all this stuff out. Write it down as it comes out – it will be a literal load off.
But your brain isn’t immediately trusting. You have to prove to your brain that the “mind dump” you did the night before works. The next morning, go through your list and handle that stuff. If you don’t, your mind will know, and even if you DO write it down, your brain will hold onto the nugget and stress you out.
The thoughts that plague your mind are a HUGE cause of insomnia. Write them down, clear them from your head. Write them in a way that TRULY gets them out of there. Here’s what I mean: If you have to call the cable company to change your service, you may want to write “Call cable company.” Your brain, though, still has some thinking to do here: What cable company? What number? When do I call them? What am I saying to them? Make your to-do lists complete, actionable items as if you were delegating them to a secretary. “Call Time Warner Cable 888-THEDEVIL to change our plan from cable + internet to just internet.”
Is your family stressing you out? Write out exactly what’s stressing you out. Write all the things that come to mind. If you’re doing the whole if they say this/then I’ll say that, get it out too. Make an actionable todo: “Call Mary’s cell 11/10 to tell her I don’t want her to cook Thanksgiving dinner because she always ruins the Turkey.”
Combined with mindfulness and meditation, a pen and paper near bed is a POWERFUL tool in combating bedtime anxiety. Just make sure you purge EVERYTHING. Write down actionable tasks. Most importantly, do the things to ensure your brain trusts in your system.
Breathing Difficulties/Sleep Apnea
When I suggest this, people often blow it off. “I don’t snore.” If you wake up frequently in the middle of the night and have checked off all the boxes of proper sleep hygiene, a sleep study is necessary. Apnea is when you stop breathing for a moment, usually because of a temporarily blocked airway. You may not even know you suffer from it. Even small amounts of mild apnea can be enough to disturb your sleep. And it’s not always connected to snoring. You’d be surprised how, more often than not, I get reports back saying “Yeah I have mild apnea that I didn’t know about.”
Cramping/Twitching/Restless Leg Syndrome
This goes back to our Cramp article. Many people have cramping or twitching legs due to dehydration or lack of electrolytes. This is a SUPER easy fix. Rarely, some of us have a neurological disorder where our legs move involuntarily – Restless Leg Syndrome. Before we assume the worst, hydrate well, eat a banana daily, or drink some high-quality coconut water to decrease or stop leg pains and movement at bedtime.
Don’t drink all those fluids to stop cramps right before bed, though. Urinary incontinence is something that most of us can’t wait to deal with as we age. It’s a rite of passage for men as our prostates grow larger than our patience. To stop frequent trips to the bathroom, cut fluids off as early as you can – 2-3 hours before bed. Don’t take any diuretic medications (blood pressure) at bedtime or night – save those for the morning. If you have a bladder problem, speak to a urologist to get this rectified ASAP.
There’s no good fix here besides proper pain management. If you have a chronic illness that causes pain, speak with your doctor and try to get affiliated with a pain management specialist as soon as possible.
People who suffer from depression often have disturbed sleep cycles and wake in the night. Proper management of the depression is critical. Therapy, medicines, mindfulness and meditation are all winning strategies for coping with depression.
Menopause is the best. Your hormones are out of whack. You get feisty quicker. It’s like an oven in here! And for many, your sleep is disturbed, usually from hot flashes in the middle of the night. Speak with your OB/GYN for safe treatment options during your transition. Stress management is key; many symptoms that come around menopause are directly connected to stress. Namaste your way through it all.
Steroids, inhalers, allergy medicines, long-acting stimulants (like Ritalin or Adderall), or even anti-anxiety or antidepressants can disturb sleep. Chronic use of sleep agents will disrupt our sleep cycle – keeping us out of deep sleep longer and longer, making sleep less restorative.
As Daniel Tosh, the wise comedian said, “It’s a third of your life, spend the money.” Save up for as long as you can to get the most comfortable mattress, pillow, sheets, and blankets you can. A stiff mattress or pillow can cause pain and discomfort, keeping you tossing and turning all night.
Practice Proper Sleep Hygiene
Sleep hygiene are the habits we follow that help us get our best sleep.
Limit sleep to a reasonable amount of time – not too little, nor too much. Don’t lounge around in bed all the day or try to force yourself to get more than what most of us need, 8 hours.
Don’t nap too frequently. If you nap, stick to half-hour or less. I recommend one at 2pm – siesta time – if you can swing it.
Avoid stimulants like caffeine, alcohol, or drugs before bed. Keep these things 1-4 hours away, if you can.
Take it easy on the food. No heavy, greasy, or spicy foods before bed.
Eat something. I’m not Gollum from Lord of the Rings. Eating a tablespoonful of nut butter and some celery before bed, for example, can provide essential macronutrients (protein and fat) to keep you satiated throughout the night. This maintains blood sugar and limits hunger.
Exercise at least 10 minutes a day. We’re basically dogs and we have to be run. Get rid of the pent-up energy we may have from a sedentary lifestyle.
Get a good routine for the 15-20 minutes leading up to getting into bed and sleeping. Warm milk. Warm shower or bath. Read a book. Yoga, stretching, meditating.
Get rid of everything distracting. The bedroom is for sleep and sex only. I broke a sweat not making a joke there. No TVs, electronics, or anything belongs in the bedroom. Keep your phone and clocks far away and out of sight, so the lights don’t distract and keep you awake.
Set up to optimal comfy. Some people like fans, some like water noises or other white noise. It should be temperate – 60-70 degrees. Soft works for some, while hard works for others.
Optimize your Sleep/Wake Cycle
Want to know the BEST way to get a solid night’s rest and reset back to the “good old days”? Go camping. Seriously.
A study from 2013 demonstrated that camping for 2 weeks without electronics restored sleep cycles.
Interestingly enough, in 2017 the authors showed that you can get pretty darn close to those results at home over just a weekend. Study participants went au naturale – no electricity or electronics as the sunset, using candlelight or fires. They kept their window shades and blinds open, letting the natural light in. After just the weekend, they were back on track.
If you can’t camp, which you should, here’s what I suggest:
- If you get out of whack, give yourself a weekend to unplug after dark. No artificial lights, no electronics.
- During the week, make a more conscious effort to turn off screens at night. If you can, use the “night mode” settings which warm the lights up.
- Open the blinds before bed and let that light shine in.
- For your house, try to get less intense, natural color light bulbs. Technology is cool, so you can get some that can change their temperature and color shade.
- The most important: go to bed when you’re tired. Wake up when you naturally feel ready to in the morning. This might mean a little earlier than you are used to.
Listen to your body. Let your body “listen” to it’s genetic cues.
Supplements for Sleep
Or you can skip all that and just chemically sedate yourself. Totally an option. Supplements for sleep support are great to help with immediate needs but should be used for a short period. My recommendation is to try one, start with a low dose, and slowly increase to the maximum recommended dosage. If the results aren’t there, toss it and try another agent. Rarely will taking a handful of supplements for sleep each night be a good idea.
We can categorize sleep products into three big groups:
- Melatonin products
- Micronutrients (like magnesium and 5HTP) that cause relaxation
- Herbs or botanicals that have sedating, relaxing, or calming effects
Supplementing with melatonin is an easy way to help restore sleep cycles. If you are a little off, using a properly made melatonin can help get the cycle back on track, but to a lesser degree than camping :).
A few important points:
- Melatonin dosing is subjective. A child could use 10mg, while a big guy like me might respond to 3mg. Start low, and increase slowly.
- A slow or controlled release formulation is best. Melatonin secretes over time, so an immediate release product (which most are) won’t really help get melatonin levels up for more than an hour or two. Our Sleep-Ease has an immediate 2.5 mg dose with a slower releasing 2.5mg.
- It’s best taken at sunset to mimic the natural course of things. Many will say, “Well then I get tired early.” Yeah, that’s the point. Your body wants you to go to bed, not stay up watching Game of Thrones.
- Try one dose for a week at least, then bump it up. If you reach 10mg with no benefit using it as I lay out here, then it may not be right for you.
Magnesium and 5HTP
Magnesium is a common supplement sold for sleep support. Magnesium, in high doses, can have a relaxing effect, especially on the muscles. Anecdotally we’ve heard 2 capsules of Easy Magnesium or a scoop of Mag Relax powder provides enough magnesium to support relaxation.
5HTP is another calming compound. 5HTP is a precursor to serotonin, so some believe it helps relieve symptoms of anxiety that may make falling asleep difficult. If someone were to try 5HTP, we’d recommend a slower-releasing product like our 5HTP over the immediate forms.
A word on tryptophan. I’m not too sure tryptophan actually helps people sleep. We think the turkey on Thanksgiving makes us tired because of the tryptophan content, but in reality, it’s the 5000 calories that make us sleepy. We are not quick to recommend tryptophan for sleep support.
Herbs and other Botanicals for Sleep
We could write a book about all the herbal products that are used for sleep. Instead, we’ll say this: Many herbs have sedating properties. They differ in how quickly they work and how long they last. Many of them are great options but deserve their own post.
Sleep with Melatonin and Valerian – This is an excellent blend of many calming herbs such as Valerian, Passionflower, and Chamomile. It contains a small dose of melatonin, so it is a win-win for some people. We recommend the liquid capsules, as the concentration is a bit higher, so fewer capsules are needed for a good dose.
CBD Oil – I’m moving towards recommending more and more for sleep support. There are a bunch of reasons why a high quality, low-cost CBD works well:
- Many of us our anxious. We REALLY need legal marijuana federally, so this will do in the meantime.
- It is quick to start working – 30 minutes to 1 & ½ hours if given under the tongue.
- It doesn’t last forever. Many herbal agents last 6-8 hours and can cause a hangover effect if used in the middle of the night. CBD lasts 4-6 hours for most people
- The doses can get real specific. If you want an herbal capsule, you’re stuck with a single, usually big dose. With CBD, you can increase or decrease for your specific need.
Call us if you’d like more CBD info!
Sweet Dreams Are Made of These
Sleep is the second most common problem we help solve in our practice.
There’s nothing more irritating than hearing someone say “You’ll get tired eventually!” when talking about your insomnia. That comes from a lack of understanding on the complications of our sleep cycle or how other diseases or conditions can impact sleep.
We’ve laid out a solid set of recommendations based on real data from the experts. “Who am I to disagree?”
Doing the work is the tough part. Sleep is a crucial component of our wellness. Getting back on track with proper sleep takes diligence and dedication to address all possible causes, but the results are worth it.
Just trying to keep it real…
Neal Smoller, PharmD
Owner, Pharmacist, Big Mouth