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Sleep

Although scientists are still trying to learn exactly why people need sleep, animal studies show that sleep is necessary for survival. For example, while rats normally live for two to three years, those deprived of REM sleep survive only about 5 weeks on average, and rats deprived of all sleep stages live only about 3 weeks. Sleep-deprived rats also develop abnormally low body temperatures and sores on their tail and paws. The sores may develop because the rats' immune systems become impaired. Some studies suggest that sleep deprivation affects the immune system in detrimental ways.

Sleep appears necessary for our nervous systems to work properly. Too little sleep leaves us drowsy and unable to concentrate the next day. It also leads to impaired memory and physical performance and reduced ability to carry out math calculations. If sleep deprivation continues, hallucinations and mood swings may develop. Some experts believe sleep gives neurons used while we are awake a chance to shut down and repair themselves. Without sleep, neurons may become so depleted in energy or so polluted with byproducts of normal cellular activities that they begin to malfunction. Sleep also may give the brain a chance to exercise important neuronal connections that might otherwise deteriorate from lack of activity.

Deep sleep coincides with the release of growth hormone in children and young adults. Many of the body's cells also show increased production and reduced breakdown of proteins during deep sleep. Since proteins are the building blocks needed for cell growth and for repair of damage from factors like stress and ultraviolet rays, deep sleep may truly be "beauty sleep." Activity in parts of the brain that control emotions, decision-making processes, and social interactions is drastically reduced during deep sleep, suggesting that this type of sleep may help people maintain optimal emotional and social functioning while they are awake. A study in rats also showed that certain nerve-signaling patterns which the rats generated during the day were repeated during deep sleep. This pattern repetition may help encode memories and improve learning.

 

Many people have trouble falling or staying asleep. As a result, they may get too little sleep or have poor-quality sleep and not feel refreshed when you wake up.  People who have trouble sleeping may try nutritional supplements in an effort to fall asleep faster, stay asleep longer, and improve the overall quality of their sleep. Research has produced promising results for some nutritional therapies. Although prescription drugs can help, they often have undesirable side effects. Many people experiencing sleep problems do not seek medical attention, turning instead to nutrition.

 



  • The herbal supplement valerian is one of the most popular therapies for insomnia. Several studies suggest that valerian (for up to 4-to-6 weeks) can improve the quality of sleep and slightly reduce the time it takes to fall asleep.
  • Like valerian, melatonin supplements (melatonin is a naturally occurring hormone associated with sleep) are widely used and researched for insomnia. Although more research is still needed, studies suggest that melatonin can help people with insomnia fall asleep faster, and may also be beneficial in patients whose sleep problems are caused by a circadian rhythm abnormality (disruption of the body's internal "clock").
  • Dietary supplements containing melatonin "precursors"—L‑tryptophan and 5‑HTP—are also used as sleep aids. (The amino acid L‑tryptophan is converted to 5‑HTP, which is converted to serotonin and then melatonin.)

What does sleep do for us?

Although scientists are still trying to learn exactly why people need sleep, animal studies show that sleep is necessary for survival. For example, while rats normally live for two to three years, those deprived of REM sleep survive only about 5 weeks on average, and rats deprived of all sleep stages live only about 3 weeks. Sleep-deprived rats also develop abnormally low body temperatures and sores on their tail and paws. The sores may develop because the rats' immune systems become impaired. Some studies suggest that sleep deprivation affects the immune system in detrimental ways.

Sleep appears necessary for our nervous systems to work properly. Too little sleep leaves us drowsy and unable to concentrate the next day. It also leads to impaired memory and physical performance and reduced ability to carry out math calculations. If sleep deprivation continues, hallucinations and mood swings may develop. Some experts believe sleep gives neurons used while we are awake a chance to shut down and repair themselves. Without sleep, neurons may become so depleted in energy or so polluted with byproducts of normal cellular activities that they begin to malfunction. Sleep also may give the brain a chance to exercise important neuronal connections that might otherwise deteriorate from lack of activity.

Deep sleep coincides with the release of growth hormone in children and young adults. Many of the body's cells also show increased production and reduced breakdown of proteins during deep sleep. Since proteins are the building blocks needed for cell growth and for repair of damage from factors like stress and ultraviolet rays, deep sleep may truly be "beauty sleep." Activity in parts of the brain that control emotions, decision-making processes, and social interactions is drastically reduced during deep sleep, suggesting that this type of sleep may help people maintain optimal emotional and social functioning while they are awake. A study in rats also showed that certain nerve-signaling patterns which the rats generated during the day were repeated during deep sleep. This pattern repetition may help encode memories and improve learning.

Let us define what is meant by proper rest: Ideally it means freedom from work or physical activity, freedom from disturbance of mind or spirit, peace of mind. The purpose of proper rest is to restore - to bring back to a former or original condition.

There are presently many theories as to why we require rest or sleep, what happens both mentally and physiologically while we sleep and even how much sleep each individual really needs. Based on the information that we have, a rational approach serves to unravel some of the mystery surrounding sleep and the essentials of proper, adequate rest.

When individuals are sleep-deprived their most common complaints are mental fatigue or confusion and musculoskeletal discomfort. Subsequent rest relieves these conditions. We therefore may extrapolate that sleep is essential to maintain mental clarity and to neutralize structural stress. The physiology behind the restoration of mental capacity is not yet well understood, however it would appear to be associated with renewing neurotransmitter chemicals and cell membrane potentials throughout our bodies. These processes in turn are dependent, at least in part, upon the length of rest, the quality of one's nutrition, and the state of one's mind. Rest also provides time for your logical, analytical 'left' brain to relax its dominance and thus allow the emotional and imaginative 'right' brain valuable time for creative expression. Thus, one of the keys to effective rest is learning how to turn down the volume of your 'left' brain while you tune into your 'right' brain! This is where the regular use of an exceptional guided imagery tape can be so useful.

The physiology behind the other major function of rest and sleep, structural recuperation, is more apparent. There is relentless force acting upon our physical structure, day by day, week after week; that is the constant force of gravity. The more effectively one learns to be aware of this force and to deal with it intelligently, the less destructive its influence. Failure to pay heed and to effectively reduce the effect of this downward pull on our bodies, often results in chronic and recurrent musculoskeletal discomfort (stiff, sore shoulders, neck, and back; hip, knee and ankle distress), degenerative disc and joint disease, myo-fascial problems and even headaches.

How then may we better cope with these stresses, especially with those related to the earth's gravity? While most of us are aware of the need for a good night's sleep, too few recognize the need for proper rest during the day. Both those who are engaged in heavy physical labor and business executives or white collar workers alike are subjected to a variety of physical stressors throughout their 'working hours'. There is mounting evidence that those who manage to obtain some rest and more resourceful postures during the day, not only live more comfortably and work more effectively, they also live longer! Once convinced of the benefits, how does one go about obtaining proper rest during business hours? Proper rest refers to "those inactivates which serve to aid restoration of optimal mental and physical function" (i.e. good health).

Our goals here include assisting the nervous system in its ability to cope with the variety of stresses imposed upon it, and assisting the physical body in compensating for the wear and tear of manual activities and the effects of gravity. All that is normally required is 15 to 20 minutes, twice daily, (in addition to your usual night sleep) to counteract the onslaught of stress-related fatigue and wear and tear.

One of the most effective practices involves getting off your feet, and/or derriere, and laying supine on your back on a firm surface. Any carpeted floor will do nicely. The knees should be bent up toward your chest until your thighs are at right angles to your trunk, perpendicular to the floor, with your lower legs resting on a chair seat, couch, or even a box with padding on top. In this position, your back is flat against a firm surface and your legs and feet are elevated above your chest, improving venous blood circulation. To give your neck better support, place a small pillow preferably contoured) or a towel roll behind your neck.

Begin by inhaling deeply through your nose and slowly, counting "one thousand, two thousand, three thousand, four thousand" as you inhale (try not to think in terms of dollars, you're relaxing remember!), then hold for at least that long or better still twice that count (twice as long) before you exhale slowly yet forcefully through your nose still and contracting your abdominal muscles slightly, - and then repeat at least 10 times. Learn to breathe through your nose and from your lower rib cage, allowing your abdomen to relax and your lungs to fill more efficiently. You will note the incredible release of emotional tension as you learn to unwind in this fashion. (See "Deep Abdominal Breathing Exercise.")

This procedure, when done correctly while concentrating on rhythmic breathing, alters brain wave patterns and helps one approach'alpha rhythm' - a state in which mental relaxation and rejuvenation is maximized without actually falling asleep. Playing baroque music softly while clearing yourself of mental clutter can assist accessing this state. Embarking on any of a wide variety of guided imagery audio excursions can be of great help here. Some favorites here are "Journey to Health" by Dr. Larry Herdener and the "Inner Smile" by Dr. Linda Berry. Try these, you'll love them! For those simply looking for a brief escape from gravity, just assume the position and catch some soft tunes if you can!

These mini vacations will allow you to enjoy the benefits of better energy; improved circulation and they will aid greatly in the restoration of muscle balance and tone. If your work habits or environment are such that you can only take one rest break a day, the best time would be prior to eating your noon meal. A second such rest could be taken upon arriving home after work, and prior to your evening meal, thereby helping to improve your digestion as well. The change in your general health will quickly become apparent and equally important - you'll feel a very definite increase in your energy level.

The need for sleep varies considerably with age - infants sleep most of the day, adults require an average of seven to eight hours and the elderly often require as little as six hours of sleep each night. In the case of the elderly, they may also 'cat nap' for varying periods of the day. The state of one's health can also have a profound effect on the need for sleep. Aberrant sleep patterns not only relate to mental stress, they can also be indicative of declaiming health and/or inadequate nutrition.

Millions of dollars are spent on drugs for the purpose of inducing sleep. Common sense should tell us that sleep for a healthy individual should be as natural as breathing. Drugs are certainly not the sensible or the health-promoting answer to poor sleeping habits. If you are one of the many who are not satisfied with your sleep habits, be certain to bring this to the attention of your health practitioner so that he/she may support you in the identification and the correction of the contributing factors to your sleep challenges. This is an essential step in the restoration and maintenance of one's health. Please be certain to address this area promptly. The answer may be as simple as changing your diet or nutritional supplements or getting more natural light, fresh air and/ or exercise each day!

Generally two of the most neglected aspects of sleep are sleeping posture, and the type of mattress on which we sleep. The combination of a sleeping posture that permits good circulation and a pillow and mattress that provide well distributed support for your skeletal structure are of primary importance. If you spend one third of your life sleeping, it only takes a quick calculation to determine that the least costly investment you'll ever make is the purchase of a sensible mattress and pillow. A sensible mattress is neither stiff as a board or soft as a sponge - it must be firm enough to provide support yet supple enough to mould to your body shape without creating pressure points.

The two best sleeping postures, on a sensible bed, are on your back with a pillow or bedroll behind (underneath) your knees, supporting your lower legs and assisting circulation, or on your side, knees drawn up slightly toward the chest, with a pillow between your knees. There are also pillows available that are specially formed or contoured to provide both head and neck support. Be certain to discuss such a pillow with your practitioner. Use of this type of pillow is as important to your neck as good footwear is to your feet! If you sleep on your back with your legs out straight and you have any history of lower back problems, you may be better off with a little support in the small of your back, such as a rolled towel or a small pillow.

Many consider their time spent while seated to be adequate rest time. Several factors must be considered here however. First, one's posture while seated dictates whether one's structure is indeed being 'rested' or in fact further 'stressed'. Thorough understanding of proper posture and constant vigilance is required here. Needless to say, most people are contributing more to stress and strain than to rest, by the seated postures which they adopt.

Proper seated posture is efficient posture. Efficient posture is the posture which requires the least amount of muscle function to maintain, thus allowing for more relaxation of muscle tone and enhanced circulation to both muscles and joint structures alike. Just imagine your torso 'dangling from a string' attached to the center of the top of your head. How would your back and shoulders be positioned? Go ahead, close your eyes, sit tall and dangle! When you think you have it, open your eyes and without moving, note the position of your head, neck, shoulders, and back. Remember that you are dangling from the center of your head, being drawn upward, your shoulders, head and neck cannot be slumped forward or arched back.

You will feel different in this posture but comfortable and you will be able to maintain this posture much longer than any other less efficient posture and remain comfortable.

Now look for seating which allows you to comfortably maintain this posture while supporting the natural forward curve in your lower back (lumbar spine). It also helps to support your lower back and pelvis by elevating your feet on a small footstool, box or crate to raise your knees just higher than your hip joints.

The reference of 'dangling from a string' will also help you orient yourself as to efficient standing posture. Try it, you'll like it, even if it feels different or awkward at first.

Whether you eat or you consume any liquids prior to going to bed is a matter of habit and individual metabolism. One person's almond and sunflower seed 'sedative' is another's 'guaranteed insomnia'. The best indication is how you feel in the morning, but generally speaking we are best making our supper the last food that we eat before bed.

If you arise with renewed vitality and fewer aches and pains than when you retired, then you are probably on the right track to proper rest; if you do not, then be sure to discuss this matter with your healthcare 'coach' as well. Proper rest is essential to good health - the 'rest' is up to you.

The Fresh Air - Relaxation Connection:

Fresh, oxygen-rich air is your most vital need. Without it you would die within six minutes. The quality of the air you breathe is so important because of the vital oxygen which it contains. Your blood and all your cells must be oxygenated regularly or death occurs. In your lungs there are a billion tiny air sacs, where your blood is purified, supplied with oxygen and sent to the rest of your body. As you breathe out, you expel carbon dioxide and other toxic waste gases. Proper breathing eliminates as much as 75% of your body's wastes! Exercise greatly assists in both the oxygenation of your cells and the elimination of their wastes. Go for a walk, a cycle or any outdoor activity each day. These activities are even more beneficial when near a beach, a park or lush vegetation, where the quality of air is superior. The best source of air is the outdoors, of course, away from large cities. Nature constantly purifies and cleans the air. Plants convert carbon dioxide into oxygen, while rain and oceans constantly recycle and clean the air all over the world. Keep a window open in your house and have numerous plants around to help cleanse the air. If you sleep in a room with the windows and doors closed, you will be breathing in air that has less oxygen and more carbon dioxide.... this is not desirable. Another important consideration is the fresh air - relaxation connection. When breathing in deep from lower in your chest your body receives more oxygen. How you breathe affects how you feel. When you breathe deeply from lower in your chest, it is a full complete breath and relaxation follows immediately. Go ahead - try it! People generally breath from their upper chest, however, and continue to wonder why they feel constantly 1stressed'. The more quickly and shallow you breathe, the more tense you become. You become more peaceful and relaxed when you take a deep slow breath. Breathing affects your emotional state; it accesses different states of mind. This deep "abdominal breathing" as we refer to it, is the key to relaxation and to improving the oxygenation of your body.

Deep "Abdominal Breathing" Exercise (For Beginners):

You can be in either a sitting or lying down position. If sifting, keep your spine erect: sit with your back straight and reach for the sky with the top of your head. Place your hands on your abdomen - one above the navel, and one on the navel. Breathe in deeply through your nose - and focus on "filling your abdomen with air": feel the navel swell out first, then feel your breath slowly rise up into your chest, expanding your entire rib cage. As you breathe out, the hand positioned above the navel will sink in first, followed by the lower positioned hand. Be sure to exhale through your nose as well and slightly contract your abdominal muscles to ensure complete exhalation. You can now experience deep abdominal breathing taking place. Conduct this deep breathing exercise for at least five minutes at a time, several times daily - you'll be pleasantly surprised with the results. As you breathe in, count to four, hold for a count of four and release the breath over a four-count. IN..l..2..3..4.. HOLD..l..2..3..4.. OUT..1..2..3..4.. HOLD..1..2..3..4.. and continue to repeat this pattern until done. Note the wave of relaxation which comes over you. Remember, practicing relaxation is like any other exercise.  The more you do it, the better you get.

A 2007 study by the National Sleep Foundation, a nonprofit research group, entitled “Women and Sleep”, found that nearly 30 percent of women in the United States used some type of aid to sleep at least a few nights per week to combat chronic insomnia. These sleep aids range from herbal remedies to nutrient supplements to complex pharmaceuticals (typically Ambien or the generic Zolpidem). Melatonin supplements are becoming popular in bars and convenience stores, as many patrons believe that a drink with melatonin or a brownie with the supplement will provide the aid to sleep and relaxation they need without the side effects of a prescription medication. While it is tempting to define a health problem by the symptom remedy and ignore the underlying implications of the health problem or problems that are causing it, this is not the sensible long-term solution to the problem of chronic insomnia, sleep disorder, or anxiety-associated insomnia. Insomnias are often resulting from an interaction of biological, physical, psychological, and environmental factors that need to be addressed with a holistic approach, and if the physical or biological disorder is related to an endocrine or metabolic imbalance or pathology, this needs to be identified and corrected. Often, a chronic insomnia or sleep disorder is the first tangible sign of a developing and serious health problem. While infrequent episodic insomnia, especially related to unusual events or worries, is perfectly normal for a healthy individual, chronic and frequent insomnia needs to be assessed professionally. Ignoring the underlying health problems causing this symptom may result in more serous problems in the future. The time to correct these health problems is before they develop into a more severe condition, and Complementary and Inegrative Medicine, acupuncture with herbal and nutrient medicine, and even Tui na physiotherapy, when musculoskeletal pain is keeping you awake, provides an array of therapeutic protocols that are now proven to work.

Standard pharmacological treatment for insomnia has been problematic for decades, with the findings of risks and adverse effects often outweighing the benefits. Even standard medicine has turned to sleep clinics promoting an array of sleep hygiene protocols instead of, or to complement, drug therapies. Sleep hygiene, or the regulation of the whole array of behavioural and environmental factors that precede and interfere with sleep, is an integral part of the protocol in Traditional Chinese Medicine, combined with herbal and nutrient medicines, acupuncture stimulation, and physiotherapies, to holistically address both the insomnia and its causes and associated health problems. As research progresses we are reaching the final stages of human clinical trials of various individual therapies in Complementary Medicine, and the results are providing positive findings of potential benefits from a variety of treatments. In the clinical setting, these treatments are combined to provide an even greater potential for success, and the potential to eliminate the underlying causes of chronic insomnia present the patient with the potential to rid themselves of this problem that decreases quality of life and work potential for good, with no future dependency on treatment, especially drug addiction, and no rebound effect.

Defining insomnia as a specific disorder has long been a challenge for allopathic medicine. The experience of insomnia is extremely varied, both in type and frequency, and normal sleep patterns for some individuals would be considered a significant problem for others in terms of function and quality of life. Generally, insomnia is reported as either a difficulty falling asleep, a problem with waking during the night, or both. Even the patient with a frequent insomnia may wake perfectly rested, and their is no specific physiological need for a specific number of hours of sleep for all individuals. We see this most dramatically with the parents of an infant, whose sleep is disturbed by the care of the baby, yet functionality and quality of life is maintained. On the other hand, some patients may sleep for relatively long periods of time and still not feel rested. Sleep clinics may study the sleep cycle with polysomnography, to see if the normal sequence of sleep phases occurs, which is important for the healthy function of the central nervous system, although this is usually expensive and only performed when a serious sleep apnea is suspected. Understanding insomnia on an individualized basis and addressing both the symptoms and the underlying causes and contributors is important, and developing a holistic protocol that addresses the biological, physical, psychological, and environmental factors to achieve real success should be the goal, not just taking a pill to sleep.

In recent years, a number of sleep experts have noted that descriptions of sleep in history often mention the ‘first sleep’ and the ‘second sleep’, describing a pattern of sleep that involved waking in the middle of the night and resting awake, or working, for an hour or two. This segmented sleep, or biphasic sleep pattern, has now been thoroughly researched, and appears to be a natural sleep pattern for humans, along with a short nap during the day. Many cultures still promote a midday nap, or siesta, cat nap, or power nap. Historians A. Roger Ekirch and Craig Koslovsky have found abundant evidence of the prevalence of this habit, with the midnight waking state used to contemplate, pray, write poetry, write religious text, meditate, or even for couples to have more relaxed and meaningful sex. Sleep studies have confirmed these findings, with subjects denied artificial light adopting a segmented sleep, and higher levels of prolactin secreted during the midnight wakeful state, which is associated with peaceful mood, healthier reproductive capability, and many neurohormonal and immunological benefits. Dopamine and prolactin are now known to cause, or be associated with, sexual arousal and sexual satisfaction. Prolactin is also a promoter of brain cell maintenance and growth. Normally, there is both a diurnal and ovulatory cycle to prolactin secretion, and it is hypothesized that higher levels in the midnight waking state could be beneficial in a number of ways. For many, anxiety about waking in the middle of the night may be unwarranted, and a more relaxed attitude and utilization of this midnight waking state could result in a more relaxed and healthy feeling during the day. It is the quality of the sleep, not the quantity, that is important, and there are a number of ways to improve the quality of sleep. A healthy sleep cycle is found to be an important tool for cognitive function and sorting of memory and data. The sleep cycles are relatively short, and even a 20 minute nap has been shown to be able to achieve this cognitive sorting and improve test scores and mental function.

The science of Traditional Chinese Medicine (TCM) looks at the symptom of insomnia from a holistic perspective that incorporates a traditional health profile combined with a modern medical assessment. In TCM, insomnia is a symptom that often reveals a type of imbalance of homeostasis as the key underlying cause, if it is not directly related to, or secondary to, a specific psychological disorder or disease as the predominant cause. Both the traditional and the modern perspective should assess the insomnia first as a primary disorder or secondary to another health problem. Four types of insomnia are traditionally assessed: 1) difficulty falling asleep, 2) waking inappropriately, 3) restless or light sleep, and 4) inability to sleep much at all. Each type of insomnia has a differential diagnosis related to the basic imbalances of yin and yang, excess and deficiency, and the visceral systems, in the traditional Daoist assessment, as well as a differential set of health problems that may be associated with each type. The Mayo Clinic lists these conditions as most often causative of, or contributing to, insomnia: chronic pain, breathing difficulties, nocturia, arthritis, lung disease, gastroesophageal reflux, overactive thyroid, stroke, Parkinsons or Alzheimers disease, cancer, or heart failure (congestive heart disease). The TCM physician assesses both the homeostatic health and the related diseases or injuries. Getting to know the patient is the first step in analyzing a differential diagnosis. Even if the patient chooses to treat with a sleep medication, utilizing TCM and Complementary Medicine to address these common causative or contributing health problems will not only cut down on the need for expensive medication, but will improve the overall health and potentially eliminate the need for the medication in the long term.

Finally, in 2012, even standard medicine is realizing the problems with merely prescribing a one-size-fits-all sleeping pill. For instance, The American Geriatrics Society (AGC) updated theBeers Criteria for potentially inappropriate medication use in older adults, and recommended avoidance of popular medications prescribed for insomnia and agitation, such as benzodiazepines, barbituates and chloral hydrate. Benzodiazepines are widely prescribed in the population and present a number of health risks, including an addictive quality, where trying to stop taking them daily results in alarming symptoms of increased agitation, high blood pressure and panic. In addition, both benzodiazepines and the popularly prescribed hypnotic sedative Ambien (zolpidem tartrate) come with FDA warnings concerning incidence of behavioral changes and abnormal thinking, including instances of complex sleep-walking behaviors. The AGC stated: “Older adults have increased sensitivity to benzodiazepines and slower metabolism of long-acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium.” The array of brand names for benzodiazepines is large, but most of the pharmaceutical names end with the suffix -pam. The AGC also recommended avoidance of nonbenzodiazepine hypnotics and sedating histamines, stating: “Benzodiazepine-receptor agonists that have adverse events similar to benzodiazepines in older adults (e.g. delirium, falls, fractures); minimal improvement in sleep latency and duration. Avoid chronic use (> 90 days).” An article in the April 17, 2012 New York Times, Science Times, speaks of the common practice of overprescribing medications to the elderly and the harsh implications of drug interactions with chronic use. The health journalist, Jane E. Brody experienced a personal dosage of this practice when her aunt was hospitalized, and nearly died, from the effects of her medications, which were not extraordinary, and included a benzodiazepine (alprazolam, or Xanax), an anti-depressant, blood pressure medications (adrenal receptor block plus angiotensin receptor block), an anti-psychotic variant for Alzheimer’s, and a synthetic thyroid hormone. This combination of drugs built up effects in a slower aging metabolic system, causing severe confusion, sleepiness and extreme weakness, including neurological and metabolic effects, in this case a very low sodium level in circulation, as well as precipitous drops in blood pressure, disorientation, and finally a fall with bone fractures. The author noted that the AGC panel now recommends alternative sleep remedies for older adults, such as an herbal and nutrient aid, sleep hygiene, or even acupuncture.

A thorough health history is important in understanding the individual causes and contributors. For instance, stomach excesses with acidity or fullness may cause an inability to fall asleep or waking inappropriately, and metabolic imbalances related to the liver and kidney are also suspect. The liver is the workhorse of the body’s metabolism, and is most active between 2 to 4 am, as the organ becomes engorged with blood and resets the metabolic balance in its diurnal pattern. Restless sleep may be related to the cardiovascular and adrenal systems, or disharmony between the heart and kidney systems, with autonomic dysfunction. Always, overt causes such as chronic pain flaring at night, problems causing nocturia, bruxism, apnea, or tachycardia are explored. In modern medicine, such causes should also be assessed on an individual basis, and emotional disturbances, digestive function, metabolic imbalances (e.g. leptin regulation), and adrenal dysfunction (e.g. diurnal cortisol levels) are commonly explored. A proper integration of standard medicine and TCM achieves the appropriate testing and thorough assessment needed to make the differential diagnosis, and then proceeds to the most conservative holistic therapeutic protocol. The type of insomnia may help the physician find the health problems causing or contributing to this symptom, and properly assessing the whole health picture and addressing these underlying causative health problems may be the key to success. If an important underlying health problem or problems are not addressed in therapy insomnia may persist despite any type of therapy. In addition, if underlying health problems causing or contributing to insomnia are merely masked with the use of a sleeping pill, these health problems are often not addressed. By addressing the underlying health problems future disease of a serious nature may be prevented, and overall health and quality of life improved now. This holistic approach makes sense on a number of levels.

The Complementary Medicine physician often takes the time to help solve the puzzle of underlying health problems, and form a treatment strategy that addresses these problems. In standard medicine it is often difficult to obtain the time needed from the attending medical doctor, and too often a prescription for sleep is written without proper assessment. When a number of health factors are contributing to a problem these need to be addressed as a whole, not just treating one piece of the puzzle, and certainly the chemical inducement of sleep does not really address these problems. Integrative Medicine will help address the implications inherent in the problem of chronic insomnia and sleep disorder, as well as provide treatments for immediate relief of insomnia. The choice is not just between the pharmaceutical or the complementary therapies. Even if the patient chooses to utilize a sleeping medication, addressing the underlying health issues is important, and a responsible patient will utilize a Complementary Medicine physician, such as a Licensed Acupuncturist, to address these health issues, as well as to decrease potential advese effects of the medication.

It is estimated that 75-90 percent of patients seeking medical care for chronic insomnia have a comorbid condition, or a causative or contributing health problem. A large long-term study of thousands of patients by the University of Wisconsin, published in 1998, found that cardiopulmonary disease, painful musculoskeletal conditions, depressive disorders, and prostate problems were frequently associated. Women and older patients made up a high majority of cases, with insomnia worse during the menopausal, or perimenopausal years, and during the menses in women prior to menopause. Hormonal fluctuations obviously are highly correlated with insomnia. A broad study at the Sleep Disorders and Research Center at the Henry Ford Hospital in Detroit, Michigan, in 2007, estimated that over 30 percent of the population suffers from chronic insomnia (more than 4 months and at least 3 times per week), with impairment of cognitive and physical function. Patients suffering from chronic insomnia are shown to have more accidents, higher rates of job absenteeism, diminished job performance, decreased quality of life, and increased health care utilization. Approximately 40 percent of patients experiencing chronic insomnia have diagnosable psychiatric problems, most frequently depression and anxiety. Hypothalamic dysfunction with abnornal regulation of corticotropin-releasing factor is central to most cases of both insomnia and depression. Diurnal cortisol levels are the most frequently used laboratory assessments for this condition, and cortisol levels in the evening and night are elevated from normal for a majority of these patients. Both urinary and blood plasma levels of cortisol and adrenocorticotropic hormone (ACTH) have been used to confirm that excessive evening and night secretion of adrenal cortisol related to hypothalamic dysfunction is the most frequent physical abnormality associated with insomnia, as well as depression with anxiety mood disorders (see study summary below).

Testing for hormonal imbalances has become easier and less expensive. Active hormone metabolites in saliva samples may be sent analysis and reveal cortisol and adrenal imbalances, as well as contributing imbalances between estradiol and progesterone. A set of samples will reveal the diurnal levels of cortisol to assess whether the hypothalamic-adrenal regulation of cortisol is improper. Often, an adrenal stress syndrome is involved, which can be corrected with a holistic approach and hormonal balancing.

The Failures of Standard Medicine in addressing sleep disorders, insomnia, and treatment of these disorders

A 1993 survey of physician education in sleep and sleep disorders in U.S. medical schools (Rosen RC et al, Sleep 1993;16:249-54), found that on average, only 2 hours was devoted to undergraduate teaching of sleep and sleep disorders, and 7 percent of medical schools undertook no sleep medicine teaching whatsoever. A recreation of this survey took place in 2011 (Urquhart DS et al, Archives of Disease in Childhood 2012;97:90-91), and a median of 2.5 hours was devoted to undergraduate premedical sleep teaching, with 13 percent of medical schools offering no sleep teaching whatsoever (see link to the British Medical Journal below). The authors stated: “Despite a key role for sleep and sleep disorders in human disease and behaviour, there is a paucity of undergraduate teaching in this subject area.”

A study published in the British Medical Journal (BMJ Open 2012-000850) and reviewed in the New York Times, Sunday March 25, 2012 (The Case for Sleep Medicine), revealed that commonly prescribed sleeping pills are associated with a fourfold increased risk of death, even for those taking fewer than 18 doses per year, and a significantly increased risk of cancer among those taking high doses. The authors state: “Agreement is beginning to build that alternatives to sleeping pills for the treatment of insomnia may be warranted.” The drugs studied include benzodiazepines, non-benzodiazepines such as zolpidem, eszopiclone, and zaleplon, barbituates, and sedative antihistamines. The BMJ Open editor in chief, Dr. Trish Groves, stated: “Although the authors have not been able to prove that sleeping pills cause premature death, their analyses have ruled out a wide range of other possible causative factors. So these findings raise important concerns and questions about the safety of sedatives and sleeping pills.”

There is also increasing concern of the combination of common sleep medication with other medications, and the potential for health risk. Often, sleep medication is prescribed due to insomnia that is caused by other medication, and alterations of neural control of the sleep cycle, as well as the breathing mechanism, from combinations of drugs, are seldom considered in assessment of chronic insomnia. The Mayo Clinic reports that “many prescription drugs may interfere with sleep, including some antidepressants, heart and blood pressure medications, allergy medications, stimulants (such as Ritalin) and corticosteroids.” Corticosteroids are commonly found in asthma medications, topical creams for skin disorders, pain and arthritis medication, and drugs to treat autoimmune disorders. The potential for insomnia secondary to common prescription drug use is high. In addition, many over-the-counter drugs contain antihistamines and stimulants that interfere with sleep, and affect neurological function. Most sleep medications come with warnings that these drugs should not be taken with alcohol or other medications as this could significantly suppress the central nervous or respiratory systems, slowing and stopping breathing. The most popular sleep medication, zolpidem (Ambien), lists potential side effects as breathing difficulties, suppression of deep REM sleep, and short-term memory difficulties. Opioid pain medications, beta-blockers for hypertension, and anti-arrhythmic cardiac drugs are also well known to cause respiratory depression. A study of chronic insomnia at the Maimonides Sleep Arts and Sciences clinic in Albuquerque, New Mexico, published in the December, 2012 issue of Sleep, studied respiratory patterns in 20 men and women with chronic insomnia, most of whom were taking sleep medication. None of the study participants suffered from sleep apnea or a sleep-disordered breathing syndrome, yet almost all awakenings by these patients were preceded by an abnormal respiratory process which led to the awakening. The study director, Dr. Barry Sanders of the non-profit Sleep and Human Health Institute, showed that respiratory dysfunction may be integral to most awakenings in chronic insomnia. The Sleep and Human Health Institute is currently studying the relationship between psychiatric medications and disorders and chronic insomnia in patients using a prescription medication to help them sleep. Such studies have not been conducted in the past, with a strong reluctance to link concurrent drug prescription to chronic insomnia disorders. This first small study is prompting larger university research institutes to further explore respiratory dysfunction and awakenings, and the role of prescription medications, including drugs prescribed to relieve insomnia, as the cause of such events.

Like most medications and surgical options in allopathic medicine, sleep medication is sometimes necessary, but the failure to support safer and healthier remedies to insomnia and sleep disorders, to adequately diagnose these problems, and the comorbid conditions that often cause them, is a matter of grave concern for patients, and a growing cadre of physicians. Integrative approaches, utilizing individualized protocols with herbal and nutrient medicine, acupuncture, cognitive and behavioral modification, and techniques of sleep hygiene, as well as seriously addressing underlying health problems with Complementary Medicine, provide the patient with the ability to regain health and not continue with a dependence on sleeping medications that often provide meager benefits and need for increased dosages over time. While a more thorough treatment protocol is more work in the short term, the promise of a better quality of life and non-dependence on drugs or therapy in the future is worth the effort.

Treatment Protocols for chronic insomnia

Insomnia may be treated both with symptom relieving therapies as well as protocols to address the underlying causes and contributors. A thorough holistic protocol will address each individual and also include behavioral and cognitive changes that may help promote a sound sleep. The choice of a more complex therapeutic protocol will provide for a great possibility that the need for therapy will be unnecessary in the near future, and that overall health will be improved. Since the associated health problems seen in chronic insomnia may impact quality of life, the ability to achieve more at work, and are associated with more severe health problems with aging, this protocol is also potentially preventive and saving the patient from future diseases and need for therapy.

Standard medicine usually prescribes a one-size-fits-all approach with a pharmaceutical. Sleep medications are considered controlled substances due to the effects being used for recreational abuse. Ambien, or zolpidem, has become the current favorite in prescription for insomnia, and is a sedative and hypnotic, as is Lunesta and Sonata. Drug interactions with adverse effects (Carbamazepin for mood disorders, Cimetidine/Tagamet for stomach acidity, Clarythromycin antibiotic, Fluvoxamine/Luvox SSRI anxiety medication) have been noted, sometime increasing the effects by competing for enzymes that break the drug down. Abnormal behavior due to central nervous system effects have also been well documented, with numerous reports of behavioral changes, complex behaviors during the sleep state such as sleep driving, and even hallucinations, sometimes tactile, have been noted in warnings associated with use. Alcohol and other CNS depressants appear to increase the risk of these adverse CNS effects and behaviors, and impair alertness and motor coordination. Often the patient with chronic insomnia does use alcohol to help fall asleep, and is prescribed other CNS depressants to treat depression and anxiety, making this problematic. Ambien is also associated with worsening depression, and withdrawal effects are common with abrupt discontinuation, disrupting the REM sleep cycle and causing daytime cognitive problems, thus leading to drug dependency. Older patients are cautioned that cognitive performance may be impacted by these sedative hypnotics. Side effects noted in 10-29 percent of studied patients include somnolence, dizziness and headache, sometimes only onsetting after chronic use, and thus not clearly associated with the drug use by the patient. Ambien also comes with a Class C pregnancy caution, with neonatal respiratory depression reported when used near term, and affecting postnatal lactation, with small amounts secreted into breast milk.

In the past there has been frequent changes in pharmaceutical protocol for chronic insomnia. Opioids and barbituates dominated therapy for many decades, then benzodiazepine receptor agonists, and later benzodiazepines themselves were popularly prescribed. Valium, or diazepam, was a heavily prescribed benzodiazepine sedative hypnotic in the 1960s and 1970s that went out of favor when the adverse effects, addiction, and harsh withdrawal syndrome became well known. Diazepam was added to heroin and synthetic heroin (Demerol) sold recreationally during this period to increase addiction. Daytime sedation and cognitive changes resulted in all benzodiazepines and benzodiazepine receptor agonists going out of favor for the treatment of insomnia. In the 1970s a new sedative hypnotic drug was marketed and heavily prescribed for insomnia, methaqualone, or Quaaludes, Sopors, or as they become well known to the teenagers, Ludes. This drug had CNS effects, and quickly became a popular recreational drug that was devastating. Not only the sopoforic effects, but the complete release from sexual inhibition made this the party drug of choice until its manufacture was mostly discontinued, and the U.S. had to impose the strictest drug controls on sale and distribution. Despite similar problems in European countries, American pharmaceuticals were able to lobby and delay substance abuse controls of methaqualone for years in the U.S. In the 1980s, a resumption of benzodiazepine prescriptions occurred, or as an alternative, sedative antihistamine medication (Sominex, Nytol, Tylenol PM, Unison), which also had negative CNS effects over time, as well as alarming symptoms of racing heart (tachycardia), dizziness, and daytime sedation. The problems with withdrawal syndromes, drug dependence, increase in depression, daytime drowsiness, memory loss, sleepwalking, and increases in urinary urgency and incontinence in the elderly led to an increased unpopularity of benzodiazepine hypnotics among the patient population. The most popularly prescribed benzodiazepine hypnotic for insomnia, flurazepam, or Dalmane, like diazepam and clorazepate, has active breakdown products that result in a clearance time for half the chemical of 11 days. This prolonged effect resulted in a buildup with nightly use, and was associated with falls, hip fractures and auto accidents for the elderly patients. A withdrawal syndrome with REM rebound also made the prescription of benzodiazepines hypnotics unpopular, often resulting in a period of insomnia followed by persistent anxiety that could last for some time. REM rebound, or episodes of prolonged REM sleep, sometimes even occurred during the same night as taking the medication, resulting in daytime memory impairment. The incidence of cardiac problems associated with antihistamine sedatives made these drugs unpopular as well, and led to some of the antihistamines being removed from the market before an outright ban by the FDA.

In the 1990s antidepressants were widely prescribed, and continue to be the drug of choice for many medical doctors, despite no randomized controlled human clinical trials demonstrating proof of efficacy. SSRIs (selective serotonin reuptake inhibitors) have a tendency to induce insomnia, and may worsen or induce nocturnal bruxism, another frequent underlying cause of insomnia. Benzodiazepine receptor agonists are still often prescribed, although most experts now agree that these should be used infrequently, and are appropriate only for transient and short-term insomnia, not chronic insomnia. Guidelines for use of sedative hypnotic drugs for chronic insomnia specify that alcohol use should be discouraged, that rebound insomnia often results when discontinuing the drug, and that noncontinuous use and the lowest effective dosage is recommended. The newest type of sleep medication, Ramelteon (Rozerem), is technically a melatonin receptor agonist, but does come with the same warnings as the non-benzodiazepine sedative hypnotics, mainly eventually triggering complex sleep activities, such as walking, driving, eating or making phone calls for which the patient later has no memory. These effects occur because these drugs affect a part of the brain that is involved in cognition of the waking state. Although Rozerem is the first sleep drug not classified as a controlled substance, common side effects of dizziness, drowsiness, fatique, tiredness and diarrhea have made it much less popular than Ambien among prescribing doctors. In addition, disruption of the menstrual cycle, decreased libido, mood changes, and problems with fertility sugggest that a drug that affects the melatonin receptors may alter the endocrine responses.

This array of warnings, cautions, and potential problems has led many patients to seek a safer and less potentially harmful treatment for their insomnia. A number of herbal and nutrient aids to sleep have thus become more and more popular in the general population, and sleep clinics specializing in cognitive and behavioral therapies, as well as transcranial electrical stimulation are now well studied and being developed as safer methods of managing insomnia. The cost of these sleep clinics are a prohibitive factor, though, while the cost of a holistic protocol in Traditional Chinese Medicine (TCM) is relatively inexpensive. As stated, TCM has utilized a program of sleep hygiene, or regulation of the habits and environment that affect sleep, within the holistic treatment protocol for many centuries, while the use of electroacupuncture with microcurrent stimulation to the scalp and ear has been incorporated in the protocol for decades. Standard medicine seems to be inspired by the successes of Traditional Chinese Medicine and the acupuncture profession.

Probably the most popular hypnotic drug is simply alcohol. In studies of patients with chronic insomnia, more than 22 percent reported using alcohol to fall asleep. Unfortunately, chronic alcohol use for sleep can lead to dependence, diminished sleep quality and efficiency, and concurrent use with pharmaceutical medications for sleep can be fatal in excess. The combinations of alcohol, pain medication, antidepressants, and sedative hypnotics has led to a number of famous deaths, including the actor Heath Ledger. Alcohol dependency for sleep is highly discouraged by all experts. A safe and benign set of treatment protocols is available from the Complementary and Integrative Medicine physician, or Licensed Acupuncturist and herbalist.

The patient that explores this realm of Integrative and Complementary Medicine for treatment of insomnia soon discovers that much scientific evidence support these therapies in TCM, as well as public popularity and clinical evidence, but more importantly, research into these complementary treatments reveals that addressing the associated and underlying health problems may be the real key to overcoming chronic insomnia, and that insomnia may be a symptom of a more serious health problem or problems that need to be addressed. This is where assessment and consultation with a Complementary Medicine physician becomes valuable. The various herbal and nutrient medicines that are now popular all have their individual strong points and effects, and of course, not all of these insomnia remedies will work for 100 percent of patients, requiring some adjustment in therapy, but the key to a real treatment protocol is in the understanding and addressing of the underlying and associated health problems. This is where a knowledgeable Complementary Medicine physician, such as a Licensed Acupuncturist, can provide real value and help solve this problem once and for all.

Understanding the most Common herbal and nutrient sleep aids

While each of us wants the simplest and least expensive remedy for our health problems, this often leads to limited benefits, adaptation to the remedy, and frustration in the long run. Simple sleep aids provide us with safe and valuable tools, but often do not solve the problem. A professional assessment and treatment of the underlying causes of insomnia are often needed for a fully successful course of therapy. Nevertheless, some very simple and benign herbal and nutrient medicines have been shown to be remarkably effective.

It is no coincidence that the 3 most popular herbal and nutrient medicines for insomnia and anxiety in the 1990s were attacked by the medical industry. St. John’s Wort (Hypericum), Kava-kava (Piper myristicum), and the common amino acid L-tryptophan were all attacked with massive campaigns to convince the public and the medical professionals that there were dangers associated with use. These herbs have been used for many centuries without problems, but when they became so popularly effective that they dramatically cut into sales of benzodiazepine medications, they suddenly were found to be potentially hazardous by the medical industry. To date, there are virtually no cases of harm, only anecdotal evidence. Numerous scientific studies at prestigious universities in the United States have now concluded that these herbal chemicals present no danger with either toxicity or drug interactions. L-tryptophan, an amino acid found in all meat and many plant foods, was temporarily taken off the market when a contaminated batch led to the deaths of 3 individuals in the United States. The Centers for Disease Control and Prevention (CDC) quickly found that the cause of death was a bacteria that had mysteriously contaminated the manufacturer in Japan. Despite this fact, the temporary ban was not lifted for about 9 years, while all other countries in the world allowed the free purchase of L-tryptophan. Despite the fact that an essential amino acid that was part of our normal food chain and physiology could not be a toxic substance, medical doctors continue, even today, to insist that L-tryptophan is potentially dangerous, and the FDA continues to provide indeterminant guidance. This cynical and unscientific advice is perhaps the greatest example of how deception has become a common part of medicine today, and how it relates only to profit, not patient benefits.

Tryptophan is one of the 20 standard amino acids that comprise food proteins, and is an essential amino acid, meaning that we need to get this molecule from food, and that our bodies depend on it but cannot manufacture the amino acid in sufficient quantity to maintain health. This is why it is called essential. The synthesis of tryptophan as a nutrient medicine was achieved in 1901, and the use of the supplement was common throughout most of the twentieth century. Tryptophan serves as the biochemical precursor to a number of important protein molecules in the body, including serotonin, niacin, and auxin. When genetic or immune problems lead to poor absorption of tryptophan, reduced blood plasma levels cause depression. This may occur in lactose intolerance as well as fructose intolerance. When malabsorption occurs, our symbiotic bacteria in the intestines, or biota, create the needed tryptophan. Decreased absorption coupled with an imbalance of normal symbiotic flora and fauna in the gut may lead to a tryptophan deficiency and symptoms of depression, anxiety and insomnia. Since a relatively high concentration of tryptophan is found in such foods as egg white, cod, soybean, pumpkin seed, and parmesan cheese, as well as meat, the possibility that there is a toxicity is nonexistent. Supplementation with L-tryptophan was found to be highly successful for a large percentage of patients that suffered from a deficiency, or who suffered from a deficiency of serotonin or niacin in the brain. A metabolite of tryptophan, 5HTP (5-hydroxytryptophan), has been found to readily metabolize into either tryptophan or melatonin as needed in the brain, and this supplement, a chemical found in the Chinese herb Griffonia seed, has also been found to be helpful in the treatment of insomnia. Both L-tryptophan and 5HTP readily cross the blood-brain barrier to reach our central nervous system. Since the regulation and modulation of neurotransmitters is so controlled and labile in our brains, though, a simple dosing with tryptophan or 5HTP may not alter the balance of neurotransmitters in the brain dramatically. This type of supplementation, within a more complete treatment protocol, though, can provide the bioavailability of creation and modulation of neurotransmitters to achieve a normal homeostatic balance.

St. John’s Wort, or Hypericum perforatum, is one of about 370 species of hypericum tree found growing around the world. The leaves and flowers are used as medicinal extracts, and two species of hypericum, japonicum and triquetrifolium, are used in common Chinese herbology. In China, Hypericum japonicum whole plant extract contains the antioxidants quercetin and quercitrin, and glycosides provide detoxificant, heat and phlegm clearing action, and the herb is used to treat hepatitis and other liver ailments, and serves to induce greater bile flow (choleretic). The herb Hypericum triquetrifolium or chinensis, Jin ci tau, contains aromatic compounds, hypericin, diones etc., and the glycoside hyperin, as well as a valuable essential oil, that is similar to the type of St. John’s Wort we use now in the United States as a treatment of insomnia and mild depression. Research in China has also found that this Hypericum extract can prevent retroviral diseases such as HIV, and acts as a anti-viral medication as well. The herbal extract is a valuable treatment for hepatitis. In Germany, St. John’s Wort is now commonly prescribed for mild depression and supported in medical guidelines with evidence from stage 3 human clinical randomized trials. In the United States, the greatest problem with the herbal extract is the lack of standardization and regulation, which leads to many products being of poor quality. Use of an assured professional product is recommended for an assured effect. Hypericum perforatum extract is believed to have a broad effect on neurotransmitter regulation in the brain, acting as a serotonin reuptake inhibitor, as well as a reuptake inhibitor of 5-HT, dopamine, and norepinephrine (noradrenaline), but in a modulatory manner. Hyperforin, a chemical constituent, has also been shown to have an affinity for GABA and glutamate receptors, helping to calm mood fluctuation and neuroexcitotoxicity. Standardized extracts are not recommended, as the other chemicals in St. John’s Wort also are found to exert antidepressive and calming effects, and the synergy of chemicals is thought to be better than a single chemical in the herb. Extracts of Passiflora, which are also approved as a treatment for insomnia in Germany, are shown to enhance the utilization of Hypericum chemicals in the brain.

The goals of therapy with these herbal and nutrient chemicals is to provide the brain with an increased bioavailability of neurotransmitters, a modulatory effect that increases homeostatic balance of neurotransmitters, and a calming of mood excitability. This should be accomplished with a minimum effective dosage, which is variable between individuals. Starting with a low dosage, and increasing the dosage until the desired effect occurs is recommended. Recent research has found that a combination of herbal and nutrient chemicals may aid the homeostatic metabolism better, with a lower dosage. The combination of 5-HTP, P5P (a Vitamin B6 needed in the metabolic cycle), St. John’s Wort, and melatonin, is often the most effective formula to treat insomnia. This formula is available as Positrol, from Vitamin Research Products.

Melatonin is probably now the most well-known aid to sleep. Melatonin, or more properly, N-acetyl-5-methoxytryptamine, is a chemical that is naturally produced in the human brain, and also manufactured in plants and microbes. Melatonin acts as both a hormone and neurotransmitter, and as research progresses on this chemical, we find that it is a very valuable molecule for a wide array of processes in the body, modulating circadian rhythms (day-night changes) of many important chemicals in the body, acting as an important antioxidant, aiding immune processes, aiding central nervous system functions, such as memory, learning, and control of motor coordination, aiding thyroid function, fertility, and of course sleep. The pineal gland in the central brain produces a quantity of melatonin from 5-HTP or other neurotransmitters, when we need to fall asleep, so that our brain functions change to accomodate the sleep cycle processes. Melatonin is now an adjunct treatment for insomnia, mood disorders, migraine and cluster headaches, ADHD (attention deficit and hyperactivity disorders), neurodegeneration (Alzheimer’s), delirium, fertility, diurnal cortisol imbalances, neurotoxicity, and even cancer. Melatonin is found in a number of medicinal herbs, including Feverfew, St. John’s Wort flower, Scutellaria baicalensis (Huang qin), fenugreek, fennel and mustard seeds, green cardamon seed, and even flax seed. The chemical is easily extracted from herbs and foods, and is readily available to the brain. The quality of melatonin in commercial supplements is suspect, as well as actual dosage, in many cases, and a professional source is recommended.

Kava-Kava, or Piper methysticum, is a pepper plant whose roots have been used for many centuries in the Pacific islands as a relaxing drink that acts as a sedative as well a stimulating mental clarity. Meta-analysis of research of the kavalactones in Piper myethysticum by the Cochrane Collaboration Systematic Review database shows that this herbal extract is proven effective in clinical placebo-controlled human trials for social anxiety. Studies in Germany have shown that the widely reported potential for liver toxicity is low, and kava as a cause of hepatotoxicity is extremely unlikely. High dosage of Kava with more extreme alcohol consumption or liver impairment is still suspect for potential adverse effects on liver metabolism, but this has not been shown to be definitive in any actual clinical case. Kava is prescribed for short-term use with low dosage, though, which has virtually no possibility of adverse effects. As stated, the extreme campaign against this herbal extract when it became one of the most popular and effective medicines for insomnia and anxiety virtually eliminated it from the market, but no FDA warnings, cautions, or restrictions were actually implemented, and the prestigious German Commission E Monographs on herbal and drug interactions states that the use of Kava is safe. The 1998 German Commission E Monographs did not even mention liver disease in its discussion of Kava adverse effects, and the report of 4 potential cases that were unsubstantiated in 2001 prompted a thorough review of scientific evidence by this commission, which found no evidence of toxicity or adverse effects with normal dosage, and only a potential for slight drowsiness or motor impairment potentially affecting driving with a very high dosage combined with benzodiazepines.

The potential for herb-drug interactions theoretically exist because the herbal chemicals, like those in St. John’s Wort, use the P450 catabolism pathway used by various pharmaceutical medications, but this has been thoroughly tested and discounted as well as likely to significantly effect circulating drug levels, which vary from individual to individual depending on the weight, general health, and level of function of the individual’s liver. The fact that these drugs using the P450 pathway to break down the drug are routinely prescribed concurrantly appears to not register with prescribing doctors or patients when assessing this risk of altered circulating blood levels of drugs. The warnings in the Physician’s Desk Reference (PDR) are routinely ignored by prescribing physicians concerning multiple prescriptions of pharmaceuticals that use the same catabolic pathways. No cases of actual injury from concurrent use of a low dosage of Kava with a pharmaceutical have been proven. A few cases of suspected liver toxicity in Switzerland in 2000 were studied and findings showed that the patients experienced an immune-mediated effect, possibly related to a genetic anomaly of an enzyme deficiency, resulting in a potential hypersensitivity reaction to a large dosing with a standardized acetone extract. These standardized acetone extracts are rarely prescribed since then, and high dosage prescription is very rare. Broad studies of Polynesian natives who regularly consumed kava drink noted no liver toxicity or adverse effect. What is unique in Kava use is that research has shown that a low effective dosage of Kavalactone will have an anxiolytic effect, while a large dose will have a stimulatory effect on the CNS. Therefore, for patients taking Kava to calm and sleep, the possibility of taking large dosages is just not going to happen.

Kava thus is an effective medicine for insomnia, especially the type of insomnia associated with social anxiety or other anxiety disorders, works at a low dosage, and is inexpensive and safe. Besides the effects of calming anxiety, Kava-kava contains chemicals that are anti-inflammatory, analgesic, antispasmodic, and muscle relaxing. Chemicals in Kava also act as a mild MAO inhibitor (monoamine oxidase B inhibitor), which exerts anti-depressant effects. Considering the low effective dosage, Kava might be considered in a larger herbal and nutrient protocol.

Valeriana officianalis is another popular herbal sleep aid. Both the leaves and flowers, and the root, have been used medicinally, and contain different chemicals. A Valerian product may thus be varied in effect. The flowers and leaves during flowering contain potent anxiolytic chemicals, such as caffeic acid, but the root of the Valeriana contains valeric acid, the potent sleep aid, sedative, tranquilizing, muscle relaxant chemical that seems to be the most active aid to sleep and anxiety. Other chemicals in the root exert sedative, GABA inhibiting, and antiarrhythmic effects. The leaves also contain potent antioxidants such as quercetin, courmaric acid, and kaempferol. Valerian has been used as a remedy for insomnia since at least the time of the great Greek physicians Hippocrates and Galen, who wrote of it in about 300 BC. Scientific studies have shown that key chemicals have an affinity for the GABA receptors and may exert mild benzodiazepine effects, calming the brain. This is a popular herbal sleep aid since it promotes a deeper sleep without any drowsiness associated, and acts in a modulatory manner, sedating agitated patients and decreasing fatique in asthenic patients. Numerous studies of potential toxicity have revealed none, while a number of human placebo-controlled blinded studies have demonstrated significant effects on relieving insomnia symptoms, decreasing time to fall asleep, improving sleep quality, and decreasing awakenings.

California poppy leaf and flower, or Eschscholzia californica, extract is also now a popular sleep aid and anxiolytic. California poppy is a prolific wild plant on the west coast, is designated as the state flower, and the Antelope Valley California Poppy Reserve in northern Los Angeles County appears to become completely covered with these flowers during the peak bloom, covering 1745 acres. The chemicals in Eschscholzia californica appear to have an affinity for benzodiazepine receptors in the brain, exerting significant anxiolytic effects without side effects or toxicity. As the popularity of alcohol glycerite extracts of the leaf and flower became popular among naturopathic doctors and their patients, a report that it was illegal to harvest California poppy was widely disseminated and became a popular belief, although their is no law against picking or harvesting this state flower. This is a curious coincidence? California poppy extract has a number of beneficial chemicals, and although its anxiolytic effects are still poorly understood, it does contain berberine, a potent anti-inflammatory, zeaxanthin and rutin, anti-cancer chemicals, and mildly sedative and muscle relaxant chemicals as well. The popularity of California Poppy extract appears to be driven more by its clinical efficacy and patient popularity than scientific evidence. The overall benefits, as with many herbal extracts, are many, though.

The use of these simple sleep aids may have the best effect when the right combination of herbs and nutrients are combined, and especially when professional extracts are utilized to guarantee the right dosage and content of the pill or tincture. In addition, each individual patient may respond better with one or another of these sleep aids. Despite the obvious need to immediately relieve symtpoms of insomnia, though, the patient should be aware that a truly effective treatment will assess and treat the underlying causes and associated health problems. Even these effective sleep aids may have little effect if the patient is being kept awake by musculoskeletal and neuropathic pain, by the need to urinate at night due to prostate problems, by anxiety and depressive disorders, by hormonal imbalances and diurnal cortisol dysfunctions, by hyperthyroidism, by gastrointestinal complaints, by cardiovascular problems, by sleep bruxism and TMJ disorder, etc. The TCM physician is able to address any or all of these health problems in the therapy. Once these comorbidities are treated successfully, these simple sleep aids may be effective. In the end, treatment of the overall health will result in a better life as well as sounder sleep.

Evidence for acupuncture in the treatment of insomnia

Scientific study of the effects of acupuncture on the specific symptoms of a disease or injury present an incomplete picture. The effects of the acupuncture treatment provide the patient with a holistic stimulation of homeostatic mechanisms to restore the complete health, not just relieve the symptom. The characterization of acupuncture as a simple method to relieve a symptom, and often characterizations that acupuncture is only good for relieving the symptom of pain is a gross mistruth. Acupuncture stimulation is a part of a complete therapeutic protocol in Traditional Chinese Medicine, not the entire treatment, and TCM provides, by its very nature, a holistic and complete therapy that addresses the underlying causes of a disease or injury, as well as relief of the symptoms, utilizing herbal and nutrient medicine, advice on behavioral and cognitive changes, and physiotherapies if needed. The acupuncture stimulation may be just a part of a larger protocol, with the various treatment modalities working together to achieve a better outcome. This is not to say that acupuncture stimulation alone is not proven to treat the symptom of insomnia. On the contrary, human clinical placebo-controlled trials have proven its efficacy, but more importantly, as research progresses, the remarkable ways the acupuncture stimulation treats insomnia are revealed in in vitro and in vivo studies in the laboratory, with polysomnography, and with laboratory data.

Examples of sound research with acupuncture in the treatment of insomnia are now numerous, although the number of double-blinded placebo-controlled large clinical trials published in standard medical journals are still few, although consistently positive. For example, in 2002, at the University of Pittsburgh, working with Kyung Hee University in Seoul, South Korea, a systematic review of the scientific studies was conducted, and the conclusion stated that acupuncture may be an effective intervention for the relief of insomnia. These researchers recognized that TCM and acupuncture sought to not only relieve the symptom, but to work on the underlying and associated health problems, and applauded this approach. The researchers stated: “As people age, they often experience insomnia, which can lead to more serious health problems. For example, if sleep is insufficient, fatigue and instability increase. These changes lead to physical and psychological weakness, which affects daily life and may bring about dangerous falls and fractures. Also depression and loneliness gradually get worse. Therefore, insomnia can produce various signs and symptoms leading to an unhealthy state. Many will seek medications to improve the quality of sleep. However, these drugs have the potential to be habit-forming and produce drug dependence; they may have a negative impact on a person’s life. Other interventions, with fewer deleterious effects, for improving sleep are needed...Acupuncture therapy has the potential to produce a positive effect when used to treat insomnia (Sok 2001). Researchers in Korea have shown that using acupuncture for insomnia can produce clinically significant results (Department of Acupuncture in Oriental Medicine 1994, Beon and An 1996, Sok and Kim 2000, Sok 2001). The use of complementary therapies for insomnia may enable individuals to experience improved health and increase their quality of life.” This study reviewed 189 separate scientific studies from all of the respected scientific medical databases. The criteria for inclusion was as strict as possible, and only 11 of these studies met this strict criteria. Most of these studies had under 100 participants, reflecting the problems with funding. The studies were conducted in clinical settings either in China or the United States. All of the studies focused on a relatively short course of therapy, with four focused on a course of therapy from 3 to 12 sessions, but the other 8 involving just one treatment. All of the studies demonstrated significant benefit. Since this meta-review in 2002, the quality and size of these studies have improved significantly.

In 2004, a study from the University of Toronto, Ontario, Canada, in coordination with the Sleep Research Laboratory and the Toronto Western Research Institute, measured the changes in endogenous melatonin secretion and various objective measures of sleep quality in response to acupuncture. Arousal index, sleep onset latency, total sleep time, and sleep efficiency were significantly improved with the acupuncture therapy, as measured with polysomnography, and anxiety scores were reduced significantly (D. Warren Spence et al; Acupuncture Increases Nocturnal Melatonin Secretion and Reduces Insomnia and Anxiety, J Neuropsychiatry Clin Neurosci 16:1 Winter 2004). Five weeks of acupuncture was performed on 18 subjects with insomnia and anxiety that had been continuous for at least 2 years. Melatonin metabolites in urine were measured diurnally, and the average concentration from midgnight to 8 am increased from 24 to 35 aMT6s per Nmol. Questionaires gauging changes in concurrent depression and anxiety showed improvement as well.

Links to other acupuncture research and meta-analysis is presented below in additional information, with links to the study summaries. While the problems of study design with concocting a “placebo” acupuncture and blinding this to the physician performing acupuncture makes the study of acupuncture meeting the criteria of these pharmaceutical trials difficult, and there is insufficient funding for large clinical trials, nevertheless sound studies have consistently demonstrated benefits of a short course of acupuncture in the treatment of insomnia. The measurement of melatonin and other biochemical markers, the use of polysomnography, and the use of brain scans such as functional MRI to objectively measure these benefits insures that the benefits were not just subjective. Comparisons to standard pharmacological therapy shows better effects with these objective measurements of acupuncture over drugs, and of course no side effects or long-term adverse effects or dependency and withdrawal problems. While the clinical trial data is not ideal, is does offer proof of efficacy.

In recent years, electrical stimulation on the scalp, a common practice in acupuncture, has also demonstrated significant benefits. A meta-analysis of studies at Harvard University Medical College have shown with randomized sham controlled clinical trials that transcranial direct current electrical stimulation over the left temporal and parietal cortex produced significant benefits for insomnia, mood disorders, and CNS functionality. A low inensity milliampere stimulation for 5-30 minutes per session was used, comparable to the electroacupuncture commonly used (The Neuroscientist / Soroush Zaghi et al / 2009). Measurement of objective benefits included the use of EEG and laboratory measurement of biochemical metabolites in urine, and standard questionaires were used to measure efficacy as well. Electrical transcutaneous stimulators are now utilized in standard medicine and approved by the FDA, although insurance reimbursement is often limited to treatment of pain when a pain specialist cites a medical necessity. These studies too demonstrate that the use of electroacupuncture on the scalp and ear is a viable and effective mode of treatment.

As late as 2007, such esteemed sources of scientific meta-analysis as Cochrane, continued to report that despite large numbers of studies showing efficacy with acupuncture and electroacupuncture for insomnia, few of these were large studies, or met the highest standards of strict placebo-control and double-blinding of both the patients and treating physicians to whether the needle stimulation was real or a supposed ‘placebo’. The summary of such analysis was that the research still did not sufficiently support acupuncture in standard treatment guidelines, but that this research did indicate that larger and more rigorous human clinical studies were needed and justified. Since 2007, most large medical research institutes have stated that these strict standards of supposed acupuncture placebo and double-blinding of both the patient and the treating physicians to the real versus sham acupuncture should be abandoned, as they produced impractical study designs and negatively affected outcomes, as well as preventing the investment in larger studies. Patients can now easily access supportive studies and see for themselves that acupuncture is indeed proven to work.

Behavioral and cognitive changes are important in a holistic protocol to cure insomnia and correct the underlying causes, as are environmental changes

Many studies are now being conducted to see if the protocols of sleep clinics have a measurable effect on chronic insomnia. Cognitive habits and established routines, changes in the sleep environment, avoidance of eating and digestive activity before bedtime, and mild increases in aerobic activity are found to be important in the treatment protocol. For instance, a 2011 study at the Universidade Federal de Sao Paolo, Brazil, of patients with primary chronic insomnia found that moderate aerobic excercise, performed either in the morning or late afternoon, demonstrated significant benefits to sleep as measured with polysomnography, and subjective measures of anxiety, depression, and total mood disturbances improved as well (see study link below). Similar study showed significant benefits compared to use of sleep hygiene education alone at Northwestern University in Chicago, Illinois. The effects may not be immediately apparent with aerobic exercise in all cases, and these studies provided for 4-6 months of a mild routine to achieve success. Other forms of activity, such as Tai Chi (Tai Ji), a traditional Chinese public health exercise in the realm of Qi Gong, have also been studied and found to be effective. A 2004 study at the Oregon Research Institute in Eugene, Oregon, enrolled 118 patients, aged 60-92, in 24 weeks of Tai Chi sessions, and found significant benefits in treating insomnia as measured by the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale, as well as mental and physcial fitness tests. Qi Gong routines in China have provided the population with mild exercise routines that also involve focused breathing and stress reduction for centuries. These simple routines may be taught and learned, performed at home with just 10 to 20 minutes per day of activity, and contribute greatly to the success of the insomnia treatment protocol.

You may wonder what exactly sleep hygiene is. The word hygiene means the science of health and its maintenance, as well as the more familiar cleanliness that promotes health. Mental hygiene is the key issue in the protocols for improving sleep quality, but a healthy daily routine with behavioral, cognitive, and environental changes are what the experts are talking about with the term sleep hygiene. This type of public health education and attention to the mind-body aspects of medicine have been integral to the practice of Traditional Chinese Medicine for many centuries, with China historically being the first country to adopt widely the promotion of healthy habits and exercises to decrease the burden of healthcare on the state. With the insomnia protocols, research supports the same type of advice we see in TCM, namely the adoption of better routines and habits, control of the environment in the home and workplace, and the adoption of simple relaxation routines before bedtime. This type of holistic protocol was addressed in the foundations of TCM literature, and is seen in various TCM texts dating as far back as 300 BC. The International Classification of Sleep Disorders states: ‘The importance of assessing the contribution of inadequate sleep hygiene in maintaining a preexisting sleep disturbance cannot be overemphasized.”

Set routines help your mind and body establish a better diurnal pattern, and take physiological and psychological stress off of the patient. By establishing a set time to turn off the television or computer, adopt a relaxation routine, and then perhaps read a relaxing book as you get sleepy, you will train your mind and body to easily improve its diurnal regulation of biochemical changes. Controlling the environment in the bedroom may be especially important. While it is tempting to use the bedroom to watch television or work on the laptop, this has been shown to be deleterious to sleep habits. Use the bed for sleep and sex, not work and entertainment. This type of conditioning will program your mind to adopt the bedroom as a trigger to achieve the biochemical changes needed to fall asleep and sleep soundly. Make sure the bed is not facing the door or a window if possible, and that temperature changes during the night are controlled. In traditional China, this is called Feng Shui, or the Daoist science of creating the healthiest environment for the mind and body. The term Feng Shui incorporates the words for Wind (flux) and Water (movement), and while this term is made superficial in concept today, it has traditionally been viewed as a very important concept in China, affecting the government, business, home and health, by promoting a sense of controlled movement and flux in the environment, which could be called the qi of the environment. A well designed bedroom may place the bed in a position that is not disturbed by the outside world, enjoys the right light in the morning, creates a soothing dimming of light before sleep, and has soothing colors and fresh air. During the day, the air is refreshed with an open window, but at night all drafts are avoided, and the temperature in the room is kept at a cool and even range. The body temperature drops during deep sleep cycles, as the circulation is directed from the peripheral tissues to the organs, especially the liver. Helping the body to achieve this temperature regulation smoothly is important.

Habits before bedtime that may improve sleep include warming the palms and soles by rubbing them together and deep breathing. Use of a heating pad to increase circulation to tissues that are painful may be helpful. A gentle massage from a partner may encourage deeper sleep as well. A few minutes of a deep breathing routine may be helpful, with slow diaphragmatic breathing achieved, a method of lowering high blood pressure proven to work at the Mayo Clinic. In this exercise, the breathing in slowly from the nose, first expanding the abdomen below the diaphragm and then the full chest expansion, pausing, and then slowly letting the breath out through the mouth, trying to count 3 to 6 seconds of outbreath, will help the body coordinate its physiological activity. Avoiding shallow breaths and puffing, or blowing the air out during the exhalation, is important, as a relaxing slow sigh and release of the breath is a reflex to relax the muscles of the chest, diaphragm, and lung. Deep diaphragmatic breathing exercise often requires some practice, and is not comfortable for many on the first try. Creating a soothing smell in the bedroom in helpful for many as well. The use of essential oils, such as amber, the mild scent of frankincense, either as a smoke or with the essential oil, is often very helpful. Other scents may also be soothing, and the patient can explore these by going to a shop that has high quality essential oils and incense and experimenting. For patients with cardopulmonary pathology or nighttime congestion, some essential oil scents can be very helpful to maintain a more open airway.

The array of techniques and advice in the realm of sleep hygiene can be complex, or the advice may be simple. The University of Maryland Medical Center offers these simple tips to try: 1) set a specific sleep schedule and stick to it, and don”t wait until you fall asleep on the couch in front of the television; 2) avoid napping during the day, or limit the nap to 30 minutes or less; 3) avoid alcohol for 4-6 hours before bedtime; 4) avoid caffeine, even in soft drinks, for 4-6 hours before betime; 5) avoid eating heavy, spicy or sugary foods for 4-6 hours before bedtime; 6) exercise regularly, but avoid moderate to heavy exercise before bedtime; 7) keep the bedroom temperature slightly cool and steady through the night; 8) eliminate distracting noise; 9) avoid using the bed for work or recreation, eliminating the use of the television or laptop in bed; 10) if you are hungry before bed, try a very light snack, such as a banana, or other high tryptophan foods, such as pumpkin seeds, almond, taro, peanut, or a cracker with wheat, barley or oats. (A cup of peppermint chamomile tea with honey may quell the desire for a sweet snack and calm the nervous system and stomach); 11) practice deep breathing techniques or yoga before bedtime; 12) establish a pre-sleep ritual, such as a warm bath, a few minutes of reading, lighting some incense, and/or placing a drop of amber essential oil on the edge of the pillow; 13) use a specific sleeping position to induce sleepiness, and if you don’t fall asleep within 15-30 minutes, don’t get frustrated, just get up, go into another room, and try reading until you again feel sleepy. Keep in mind that segmented sleep, or a sleep pattern with periods of sleep divided by a period of wakefulness in the middle of the night is proven to be natural pattern for humans throughout history, not a cause of alarm, or anxiety. Experiencing a period of wakefulness in the middle of the night is not the cause of tiredness, cognitive dysfunction, or daytime anxiety. A dysfunctional sleep cycle is a problem, not a segmented sleep pattern. Work to achieve a deeper and more restful sleep, not an 8 hour continuous sleep. Experts that study insomnia find that most patients with chronic insomnia stubbornly ignore these simple human habits of sleep hygiene. By focusing more objectively on specific problems with sleep quality and underlying causes of sleep dysfunction success with restfulness will be achieved.

Medications that may cause or contribute to chronic insomnia

Patients are unaware that many medications may cause wakefulness and inhibit sleep. Individuals react differently to specific medications, and often the prescribing doctor is reluctant to address this issue, either out of concern that the patient continues with their drug therapy, or that the patient will be displeased and potentially sue. This leaves the patient to gather this information and make decisions concerning the needs for the medication and the option of discontinuing use to achieve a better sleep and rest. Of course, these issues need to be discussed with the prescribing physicians. The Mayo Clinic offers this advice: “Older people use more prescription drugs than younger people do, which increases the chance of insomnia caused by a medication.” Dr. James Wellman M.D., director of the Sleep Disorders Center of Georgia in Augusta, stated in an interview that “certain heart, blood pressure, and asthma drugs, as well as over-the-counter medicines for colds, allergies, and headaches, can interrupt normal sleep patterns.” Some medications that are prescribed for insomnia include warnings of adverse effects that cause insomnia. For instance, the benzodiazepine Temazepam, called Restoril, comes with these side effects listed by the National Institutes of Health on PubMed Health: hangover effect (feeling groggy the next day), drowsiness, dizziness; rebound effect when stopping the medication, with difficulty falling asleep or staying asleep, and the possibility of depression, muscle cramp, or tremor. In addition, the FDA issued drug warnings for Temazepam (Restoril) in 2009 that warned of the possibility of behavioral changes, “sleep-driving”, other complex “sleep-walking” behaviors, and anaphylactoid reactions.

The list of medications that could affect sleep include SSRI antidepressants, oral contraceptives, anticonvusant medications (often prescribed for other conditions as well), attention deficit and hyperactivity disorder (ADHD) medications (Ritalin et al), decongestants, cortisone or corticosteroid medications (such as sprays, inhalers, and lotions, as well as pills), beta blockers (often prescribed for heart problems or hypertension), beta adrenergic agonists (inhalers and pills, such as asthma inhalers, heart anti-arrhthmyia medications, etc.), diuretics, statin drugs to lower cholesterol, appetite suppressants and weight-reduction medications, and quinolone antibiotics. Antihistamines often make one groggy and sleepy, but can also stimulate the need to urinate at night, disturbing the sleep. Higher dosage of synthetic thyroid hormone may cause or contribute to insomnia. Some pain relieving medications contain caffeine, such as Excedrin, Anacin, and Motrin Complete, and thoughtful choice of pain medications before bedtime is important. As stated, higher dosage of some common herbal medications, such as Kava and St. John’s Wort may overstimulate, and the individualized dosage is important. More rarely, some individuals respond with overstimulation when taking Sam-E or melatonin. Each individual may respond differently. Of course, the combination of these medications increases the chance that your insomnia is related to medication side effects.

Information Resources

A 2007 overview of isomnia is presented here by the Sleep Disorders and Research Center of the Henry Ford Hospital Sleep Center in Detroit, Michigan, with links to many important research summaries: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978319/ A 2001 overview of insomnia medications by the University of Colorado School of Medicine and Sleep Disorders Center of Southern Colorado provides much information:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181172/ A 2011 review of the study of sleep medicine in medical schools published in the Archives of Disease in Childhood found that past studies showed only an average of 2 hours devoted to the subject in undergraduate premedical school study, and 7-13 percent of medical schools undertook no sleep medicine teaching whatsoever: http://adc.bmj.com/content/97/1/90.2.full A 2011 study of sleeping medications published in the British Medical Journal found a more than fourfold increase in risk of death, even for those taking fewer than 18 doses of sleeping medication per year, and a significant increase in cancer risk, for those taking most of the common sleepin medications, raising alarm among physicians and a changing attitude about safety and the need to find alternatives: http:/group.bmj.com/ A conservative fact sheet on Valerian from the Office of Dietary Supplements of the National Institutes of Health showed that only a few well-designed placebo-controlled double-blinded studies have been conducted that meet their criteria, but that evidence of significant proven benefit is seen in improvement of insomnia symptoms, equivalence to a pharmaceutical benzodiazepine, no side effects, and no disruption of the sleep cycle. A study showed that a professional aqueous extracts showed significant benefits in time required to fall asleep, sleep quality, and decrease in awakenings for patients, while a commercial product containing a very low dose of valerian combined with hops had no significant effect:http:ods.od.nih.gov//factsheets/valerian/ A randomized clinical study in 2008 at Justin-Liebig University Geissen, Germany, of the effects of a low dose of valerian and hops showed significant benefit to relieve insomnia over placebo. The study used EEG to evaluate the sleep cycle and brain activity, noting improved sleep cycle: http://www.ncbi.nlm.nih.gov/pubmed/18559301 A 2003 review of medical studies of an experimental nature of acupuncture for the treatment of insomnia from the University of Pittsburgh in 2003 showed that of all quality studies found in the databases from 1990 to 2002, a review of the studies shows that acupuncture may be an effective intervention in the relief of insomnia.http://www.ncbi.nlm.nih.gov/pubmed/14651709 A 2012 study at the Chiayin Branch of Taichung Veterans Hospitals in Taiwan, Department of Psychiatry, found that a human randomized controlled clinical trial showed that a course of 4 acupuncture sessions improved insomnia and sleep quality significantly, and as well as patients prescribed Zolpidem (Ambien), based on the Pittsburgh Sleep Quality Index. Ambien (zolpidem) causes dyspepsia and diarrhea in a significant percentage of patients over time, and has sometimes alarming withdrawal effects of nervous agitation, depression, nausea, tremor and/or sweating, prompting many patients and doctors to seek more conservative treatment such as acupuncture and herbal medicine:http://www.ncbi.nlm.nih.gov/pubmed 22981051 A 2009 review of medical studies of acupuncture in the treatment of insomnia, including both clinical trials and case series, by the Emory School of Medicine in Decatur, Georgia, found that of 30 studies meeting criteria, 93% of the studies showed positive treatment effects. Of the twelve clinical trials reviewed, only three were double-blinded (a requirement no longer recommended for acupuncture trials since the creation of a sham treatment that is blinded to the physician performing the treatment is too restrictive a requirment in design). The 12 clinical trials did compare to other treatments or use a placebo, or sham, acupuncture. Of course, although demonstrating significant positive treatment outcomes, these clinical trials were not considered large enough to make a definitive statement.http://www.ncbi.nlm.nih.gov/pubmed/19097814 A 2007 review of medical studies of acupuncture for the treatment of insomnia at Penn State University College of Medicine found that for the clinical trials and case series found in the published literature, or standard medical journals, all of the studies consistently indicated significant improvement for insomnia with acupuncture treatment.http://www.ncbi.nlm.nih.gov/pubmed/17631261 A 2009 review of medical studies of acupuncture for the treatment of insomnia at the University of Hong Kong found that 20 randomized human clinical trials met strict criteria in published journals, and that acupuncture stimulation with traditional needling was found significantly more effective than benzodiazepines for treating insomnia, as was compared to sham acupuncture, showing significant benefits over placebo in a small number of trials. Sham acupuncture, the placebo in these trials, is actual acupuncture stimulation itself, and does have benefits as well, even though the point selection may not be ideal.http://www.ncbi.nlm.nih.gov/pubmed/19303356 A 2009 study or auricular acupuncture for the treatment of severe insomnia at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, found that 100 percent of patients obtained significant benefits over sham acupuncture treatments as measured with polysomnography and a followup showed longterm benefits.http://www.medicalacupuncture.org/aama_marf/journal/vol13_3/article4.html A 2009 listing of acupuncture studies related to insomnia and the comorbid conditions often seen is presented on this acupuncture website from Portland, Oregon.http://www.bodyinbloomacupuncture.com/articles A 2011 study of the effects of moderate daily aerobic exercise, performed either in the morning or late afternoon, on chronic primary insomnia found significant benefits as measured with polysomnography at the Federal University of Sao Paolo, Brazil, Department of Psychobiology. http://www.ncbi.nlm.nih.gov/pubmed/22019457 A 2012 randomized clinical study of acupuncture versus the medication zolpidem, called Ambien, at the Chiayi Branch of Taichung Veterans Hospital in Chiayi, Taiwan, found that standard acupuncture treatment once a week for four weeks produced the same significant benefits to improve sleep in primary insomnia, as measured on the Pittsburgh Sleep Quality Index, as Ambien. U.S. FDA drug warnings in 2009 for Ambien included abnormal thinking and behavioral changes, “sleep-driving”, fatigue, anxiety, nervousness, dyspepsia (poor gastric function), frequent joint and muscle pain, rhinitis, headache, and more frequent urinary tract infections: http://www.ncbi.nlm.nih.gov/pubmed/22981051 A 2010 study of the effects of moderate daily aerobic exercise combined with sleep hygiene education compare to sleep hygeine education alone showe significant benefits from moderate aerobic exercise in a study at Northwestern University in Chicago, Illinois.http://www.ncbi.nlm.nih.gov/pubmed/20813580 A 2004 study of the effects of Tai Chi (Tai Ji) exercises for the aging population with chronic insomnia demonstrated significant benefits at the Oregon Research Institute in Eugene, Oregon. http://www.ncbi.nlm.nih.gov/pubmed/15161452

Sleep Disorders and the implications to the general health

Sleep apnea is a very prevalent disorder with rising incidence in the United States. It is estimated that greater than 6% of women and 4% of men suffer from sleep apnea, or the temporary stopping of breath during sleep. This may be an underestimation, as persons with mild sleep apnea usually will not seek a medical diagnosis. An apnea episode is defined by at least a ten second interval between breaths, with either a momentary neurological arousal from sleep, or a blood oxygen desaturation resulting. These episodes are normal in sleep, especially in people that snore, but create a serious disorder when there are greater than five episodes per hour during sleep, and are clinically designated as needing therapeutic measures when there are over twenty episodes per hour in sleep. Clinical diagnosis is achieved with an overnight sleep study called a polysomnogram. State of the art clinics are now using a device that is sent home with the patient called an at-home device with web-based diagnostics, created by Watermark Medical, which accumulates the polysomnogram data with less expense and patient inconvenience. A polysomnogram measures the extent of deep sleep, or REM, by monitoring brain function with EEG, rapid eye movements, muscle firing with EMG, and heart rhythm with ECG. All of these important bodily functions coordinate with breathing and blood oxygen levels, and when breathing is disrupted too often in deep sleep states, or when deep sleep states are interrupted or decreased in frequency, health problems may occur over time. The challenge to understanding this complex disorder for the patient is one of understanding the entire health mechanism responsible, and the implications that this whole, complex disorder has on your health.

When you are diagnosed with sleep apnea, you should realize that this is almost always signifying a complex health problem that you should learn about and treat with a more holistic approach than standard allopathic medicine generally prescribes. The Complementary Medicine physician, or Licensed Acupuncturist and herbalist, can help you understand this problem and address the variety of health issues that you may need to correct. Recent studies at UCSF have shown that the risks of developing cognitive impairment and neurodegenerative disorders are doubled after 5 years of sleep apnea. Simply depending on a continuous airway pressure device (CPAP) to control apnea will not remove the underlying health problems or serious health implications of these underlying problems and the chronic airway obstruction.

Chronic sleep apnea may present a wide spectrum of health concerns. The implications of sleep apnea are foremost a lack of deep sleep and a sense of fatique, but there is a high association with cardiovascular disease, metabolic syndrome, adrenal fatique, hormonal imbalance, weight gain, ovarian cysts, neuroendocrine imbalance, hypertension and depression/anxiety disorders. Recent evidence also shows a strong relationship to neurodegenerative states and cognitive impairment, perhaps due to decreased oxygen causing buildup of beta amyloid plaques or increasing inflammation and oxidative damage (Yaffe, UCSF 2011). While each patient presents uniquely in such a complicated scenario, a diagnosis of sleep apnea should be a sign to the patient that a holistic assessment of their health is in order. Allopathic medicine tends to oversimplify the implications of sleep apnea, ignoring the underlying causative imbalance and utilizing treatment to control symptoms, while suggesting that weight loss is in order. This approach will not address the various systemic imbalances that led to the onset of sleep apnea, and underly this diagnosis, and patients with an underlying metabolic disorder and insulin resistance will have much trouble losing weight with normal exercise and dieting. While many patients with sleep apnea may need to utilize an airway machine, mouthpiece, or even surgery, these treatments do not address the underlying causes of sleep apnea, and probably do not significantly reduce the associated risks if these underlying disorders are not addressed. For many patients, sleep apnea may be a warning sign that serious underlying health problems now need to be assessed and dealth with.

As the incidence of sleep apnea has grown in the United States, so has the scientific understanding of the mechanisms that create this condition. Of course, we have looked for the simplest explanation, but the truth is that for many patients with sleep apnea, a simple explanation has not produced a clear understanding of the pathology. Research into the pathology of sleep apnea has instead revealed an increasingly complex set of causes and effects. Since modern allopathic medicine has little to offer therapeutically to correct this complex set of physiological causes, a simplistic explanation is usually offered the patient, more to fit the treatment than to address the actual individual health problems. The truth is that for most patients with a serious sleep apnea there is complex set of obstructive and neurohormonal causes.

There are three categories of sleep apnea, central, obstructive, and complex (a combination of central and obstructive). There is ample evidence now that most cases are a complex disorder, although if there is no obvious serious hormonal disease, standard medicine is reluctant to diagnose the patient with a central sleep apnea. Central sleep apnea implies that the origin of the apnea episodes is in the central nervous system, and is usually associated with a neurohormonal disorder. Since we now know that many neurohormonal disorders are subclinical, meaning that they do not fit the prior definitions of serious clinical disease presentation, this aspect is still not addressed properly with standard diagnostic assessment in many hospitals and clinics. Obstructive sleep apnea is thus the most prevalent diagnosis in standard medicine, although most experts in this realm now agree that a majority of disorders fit the complex category, and are a combination of obstructive and central health problems. Assessment of subclinical endocrine and metabolic disorders may be the key to reversal and cure of sleep apnea for most patients.

While standard medicine continues to diagnose most cases of sleep apnea as an obstructive type, the obstructive causes are complex, with airway obstruction related to unnatural relaxation of the muscles around the soft palate, or base of the tongue, enlarged structures in the upper throat, such as the tonsils and uvula, increased fatty tissues around the pharynx, and sleep posture. Even nasal polyps and nasal septum deviation have been implicated in some cases. Assessment often is determined by the specialist favoring a surgical or pharmacological approach, and since these treatments have a poor rate of success, control of symptoms rather than treatment of causes is by far the most prevalent approach in standard medicine. By far, though, in research, the most prevalent assessment of sleep apnea concerns changes in the tissues related to weight gain with metabolic syndrome, insulin resistance and hormonal imbalance. These issues may also be related to neurohormonal imbalances that affect the nervous system's response to changes in the oxygen and carbon dioxide content in the blood, oxygen content of the red blood cells, and changes in regulatory responses of respiration related to serotonin and norepinephrine diurnal levels. Poor function of the hypothalamus in relation to corticotropin releasing hormone neurons and adrenal stress appear to central to the underlying cause of sleep apnea (see the article cited below). The subject of sleep apnea has thus become another prevalent disorder that is difficult to understand, and thus difficult to treat. The proactive patient is taking the time to both better understand the disorder, and to seek out the knowledgeable Complementary Medicine physician to help deal with these dysfunction with a holistic approach.

Standard therapy for obstructive sleep apnea is still centered on cumbersome means of allowing the patient to achieve decreased incidence of apnea, with the use of a machine and mask to push increased air flow into the lung, and custom made mouth pieces that hold the airway open. The machine is called a continuous positive airway pressure device (CPAP), and is recommended when the respiratory disturbance index exceeds 20 episodes per hour. The noncompliance rate for this therapy, though, is very high, with complaints of excess noise, dry nose and throat, increased allergy symptoms, mask discomfort, cold or warm sensations disturbing the sleep, disturbance from the tubing with sleep movements, excess air in the stomach, and problems with reconnecting the device when waking to urinate and being too sleepy to reconnect. Many patients also report that these discomforts prompt them to remove the mask during the night in their sleep, or in a sleepy state. Often, the prescribing M.D. will also prescribe various medications to counter the increased allergy symptoms expected, sleep medications, etc. There are few studies that examine compliance and effectiveness of the machine and mask in the general population, although, studies in a controlled environment prove effectiveness in reduction of apnea. In other words, we know that CPAP is effective in the clinic, but we don't really know if it is effective at home. For this reason, many patients opt for a custom fitted mouthpiece to decrease sleep apnea and maintain an open airway. Satisfaction with custom made mouthpieces are high, but often these prove to decrease snoring but have not been proven to have enough effect to significantly reduce serious sleep apnea, and therefore are generally prescribed for mild to moderate obstructive sleep apnea. For many patients, a surgical approach is also recommended, with removal of enlarged tonsiles as well as reduction in the enlarged tissues of the soft palate. As is often the case, standard therapeutic methods often lack a complete solution for many patients, and these patients often look to Complementary Medicine to both enhance the effectiveness of therapies to control sleep apnea, as well as to address the underlying causes, and decrease the serious health risks.

What is still lacking from this equation is the treatment for the underlying causes of obstructive sleep apnea, which include metabolic syndrome, insulin resistance, weight gain, hormonal changes, andrenal fatique, poor hypothalamic function, and possibly subclinical hypothyroid conditions. Also, the prevalence of jumping to the conclusion that the disorder is completely an obstructive sleep apnea often means that the patient is not sufficiently assessed for a diagnosis of central sleep apnea. The term central sleep apnea, as stated, implies that a disorder in the central nervous system, or regulatory brain centers, is involved in the apnea process. Central sleep apnea could explain the scientific findings of unnatural relaxation of the muscles around the soft palate, that may relate to altered dopamine metabolism in the part of the brain called the substantia nigra, which controls muscle coordination. Patients and physicians should always consider that the problem of sleep apnea that occurs during the premenopausal to postmenopausal states, when hormonal and metabolic imbalances are common, are probably complex. Patients with sleep apnea and obesity, or metabolic syndrome, should also realize that the apnea is a complex type, even if signs of obstructive changes are evident. By failing to address the implications of central sleep apnea in the complex syndrome, the patient and physician may be making a mistake that has serious consequences in the future.

While the patient naturally seeks a simple solution to sleep apnea, these simple solutions are usually inadequate to address the health risks associated and restore the patient fully to an optimum state. Even surgical approaches usually do not achieve the success hoped for. This is often accounted for by an assumption that there is more tissue obstruction present than is treated by the surgery, but in reality, the underlying causes probably are singificant in many of these cases, contributing to the sleep apnea. In addition, surgical approaches do not stop the physiological mechanism that created the enlarged tissues in the first place, and there is an expectation that this enlarged airway tissue will regrow. The patient that undergoes tissue reduction should also consider a more comprehensive and integrated protocol to reduce the underlying causes to prevent this regrowth of obstructive tissue.

There is often no magic pill, or simple solution, to sleep apnea and the associated symptoms of fatique, weight gain, anxious depression, hypertension, cognitive impairment and neurodegeneration, etc. The wise patient seeks to better understand this complex disorder, and take a proactive step-by-step approach to correcting it, utilizing an integrated team and Complementary Medicine. Simple decrease in the symptoms of fatique and less waking during the night do not mean that all of the negative health issues are now resolved. This article, and other articles on the website, such as those addressing Metabolic Syndrome, seek to help the patient better understand sleep apnea and the related syndrome of health problems. Of course, as you read the article, you must understand that each patient is unique, and not all of these health problems are seen in each individual. You need to apply the information to your specific array of health issues when formulating a better proactive approach to help solve the problem and decrease the future health risks.

The relationship between obstructive sleep apnea, insulin resistance, and metabolic syndrome

It is widely acknowledged that increased accumulation of fatty tissue in the upper airway tissues is responsible for obstructive sleep apnea. While utilizations of machines to force more air throught these airways, mouthpieces that open the airways more, and even surgical correction to reduce these tissues may indeed temporarily open the airways and relieve symptoms, the thinking patient wonders what has actually led to this condition. Fatty tissue accumulation is regulated by our hormonal system, or endocrine function, which needs to be in balance for us to maintain optimal health. By separating sleep apnea from the associated hormonal and metabolic imbalances that underly the condition, we ignore serious health risks that threaten our health as we age.

The control of fatty tissues in our bodies is a complex issue, but is tied to the hormonal regulation by insulin, and affected by a host of other hormones. The pioneer of bioidentical hormone therapy, Dr. John Lee, found that progesterone deficiency was often intricately tied to insulin resistance, which is a hallmark of metabolic syndrome. This is one piece of the puzzle when looking at this problem holistically. In Metabolic Syndrome and obesity, insulin resistance, or resistance to the effects of insulin hormone at cell receptors, which is due to a variety of factors, is the focal issue. This insulin resistance creates an episodic excess response of insulin secretion. Insulin is a steroid hormone secreted by the pancreas that affects our sugar and fat metabolism in a complex manner, and has a host of effects in our bodies. Hormones are simple molecules that do nothing on their own, but act by affecting a wide variety of cell receptors. Insulin does have a direct impact on the regulation of fatty tissue accumulation, and insulin resistance does have the effect of increasing the density of fat cells and tissues to compensate, which is central to the pathology of obstructive sleep apnea. In addition, a number of other hormones have a strong synergistic relationship to insulin in the regulation of fat metabolism, and tissue changes, and some of this physiology is explained below. Abnormalities of adiponectin metabolism have been directly linked to fatty tissue accumulation in muscle, as well as in organ tissues. A 2009 study (cited below) at the Prince of Wales Hospital Research Laboratories in Sydney, Australia, found that fat mass and high molecular weight, or altered, steroid hormones, as well as insulin resistance were directly related to adiponectin metabolism. The researchers found that insulin resistance was higher with imbalances of fat mass, estradiol (the most active estrogen) and progesterone, and lower when adequate adiponectin was observed. The researchers concluded that there were strong negative associations between circulating adiponectin, and some of its high molecular weight isoforms (variations), and progesterone, and that progesterone and estrogens are likely to affect insulin sensitivity through modulation of adiponectin and body fat.

Adiponectin is the hormonal molecule found to be the link between abnormal fatty accumulation in tissues, insulin resistance, and the steroid hormones, especially progesterone and the balance between progesterone and estrogen, with relative estrogen dominance. Adiponectin is a protein hormone that modulates a number of metabolic processes, including glucose regulation and fatty acid breakdown (catabolism). Adiponectin is secreted from fat cells and is usually found in abundance in circulating blood, where is must stay in balance with other circulating hormones to achieve correct homeostasis of the fatty metabolism. Adiponectin has been found to play a major role in the body in suppression of metabolic imbalances, including metabolic syndrome (type 2 diabetes), obesity, fatty liver disease, and atheroclerosis. Like all hormones, this molecule is simple, and the activity generated from adipose is related not to the molecule itself, but to the hormonal receptors that it stimulates. Expression of these receptors is correlated with insulin levels, and has been found to be reduced when there is diabetes or metabolic syndrome present.

Insulin sensitivity and the homeostasis of blood sugar regulation are negatively impacted by both intermittent hypoxia (decreased blood oxygen) and sleep disruption. This presents a viscious cycle in sleep apnea. Some scientific studies have also linked insulin resistance and metabolic syndrome to complex sleep apnea independent of obesity. Patients that are not visibly overweight are not exempt from problems of sleep apnea related to metabolic dysfunction and insulin resistance. These studies have shown that insulin levels and the immune mediator cytokines interleukin-6 (IL-6) and TNFalpha are elevated in sleep apnea syndromes independently from obesity. Insulin is a hormone secreted by the pancreas that does more than just regulate blood sugar. Insulin, TNFalpha, IL-6, and isoproterenol have all been found to effect the regulation of fatty tissue creation and degradation by downregulating the enzyme activity of adipose triglyceride lipase in fat cells. The depression of the normal enzyme function results in increased accumulation of fatty tissue in the upper airway structures. We see from such analysis that a variety of factors may work synergistically to create the tissue growths in obstructive sleep apnea.

To better understand how insulin dysfunction is related to abnormal tissue growth in obstructive sleep apnea, we may look at the immune dysfunctions, to adrenal stress and fatique syndromes, and potentially to the use of medications, to see how an array of problems might be involved in this airway tissue hypertrophy. Isoproterenol is a synthetic sympathomimetic beta adrenergic agonist, meaning that it is a drug that acts like an andrenal hormone and affects the body like a sympathetic neurotransmitter. This drug is used mainly to treat racing heart (tachycardia), fibrillation, and hypertension, but is now also used to treat asthma, bronchitis and emphysema (COPD), often in combination with other drugs. Studies like the one cited above show clearly how chronic adrenal stimulation, inflammatory conditions, and metabolic imbalance can directly work together to create the fatty tissue growths seen in obstructive sleep apnea. It is widely accepted in the last few years that this combination of adrenal stress syndrome, chronic inflammatory dysfunction, and metabolic syndrome are probably responsible for the rising incidence we see in obstructive or complex sleep apnea. We see that this scenario could form a vicious cycle, with decreased intermittent blood oxygen negatively impacting insulin sensitivity, and changes in insulin sensitivity disrupting the normal regulation of fatty tissue accumulation, or in other words, insulin resistance and metabolic disorder eventually causing sleep apnea, with sleep apnea worsening the insulin resistance and metabolic syndrome.

Hormonal imbalances may also change the sleep cycle and create added stress on the regulation of breathing at night and apnea. In pregnancy, a number of hormones are secreted at much higher levels, and these hormonal effects have been well studied. Increased estrogens may inhibit REM sleep, and increased progesterones may promote more non-REM sleep time. Cortisol, an adrenal hormone, may also modify sleep patterns, and increases in hormones stimulated by the hypothalamus and secreted by the pituitary, such as prolactin and oxytocin, may also alter the sleep cycle. Prolactin increases prolong the duration of REM sleep time, and oxytocin may lead to excessive sleepiness. Studies of increased hormone levels in pregnancy also show that increases in estogen secretion may cause mucosal edema and upper airway resistance. Estrogen drives the weight gain and tissue growths in pregnancy, and often the pregnant woman develops snoring patterns and may then develop obstructive sleep apnea. Increased progesterone secretion in pregnancy may also act on the brain respiratory control centers (ventrolateral medulla) to reduce blood CO2, which may contribute to sleep apnea onset. These studies in pregnancy may be applied to the general population as well. When changes in the levels of estrogens and progesterone occur, both the sleep cycle and tissue growth and edema may be affected, as well as respiratory regulation. Especially in perimenopausal and menopausal states, levels of estrogens and progesterones change, and this is the time when many women experience the onset of sleep apnea. Throughout life, especially for women, subclinical hormonal pathologies may occur, causing premenstrual symptoms, infertility, polycystic ovarian syndrome, subclinical hypothyroidism, and hypothalamic dysfunction. Sleep apnea occurs most frequently in the female population, and these subclinical hormonal changes and stresses may play a significant role in the pathology.

Most patients acquire the health problems that lead to sleep apnea gradually, but when faced with the consequences to their health, such as the now noticeable fatique that results from unrecognized sleep apnea, they look to the physician for a quick and easy fix to the problem. For the acupuncturist, the patient may ask if it is possible to cure their sleep apnea with a few acupuncture sessions. Obviously, the patient and the physician should look further than the surface with this problem and correct the underlying conditions, and well as the problems with general health that both worsen the sleep apnea as the sleep apnea worsens the underlying health problems. While standard medicine is helpful to decrease the incidence of sleep apnea with devices or surgery, it does not adequately address these chronic underlying health problems that will perpetuate the condition and add to future health risks. This is why the patient must try to gain some understanding of the problem and work with an integrated team of physicians, utiizing Complementary Medicine to regain a health homeostasis and stop the problems that cause and worsen the condition of obstructive or complex sleep apnea.

Numerous sleep studies have investigated the connection between increased weight, increased fatty tissues in the airway that lead to obstructive sleep apnea, and metabolic changes. A study cited below shows that sleep deprivation consistently leads to reduced leptin and elevated ghrelin, resulting in poor appetite control, excess appetite, craving for simple carbohydrates, and increases in BMI (body mass index), or fatty tissues. Leptin is a protein hormone that is created by fat cells to control appetite, affecting the regulatory centers in the brain, especially the hypothalamus, and is integral to insulin resistance and Metabolic Syndrome. Much research has now been conducted concerning leptin, and animal studies indicate that leptin is a stimulant of ventilation, as well as a role player in tissue development of the respiratory system. Leptin is being investigated not only as an important regulatory hormone affected by sleep deprivation, but as a potential causative factor in the pathology of sleep apnea when leptin deficiency or leptin resistance is evident. The Curie Institute in France has studied the subject of obesity thoroughly and concluded that chronic inflammatory dysfunction appears to be at the heart of this problem, the inability of the body to use stored fats in the metabolism, thus creating weight gain that is impossible to reduce, or a high BMI index. When this occurs, the white fat cells, which produce most of our leptin, become dysfunctional, resisting the insulin signals, and not producing sufficient leptin. We see how a number of factors work together, or holistically, to create this bad situation. Allopathic medicine looks to one step in this cycle to alter to correct the problem. An intelligent analysis concludes that we must affect the whole cycle of metabolic and inflammatory dysfunction to achieve real success.

Ghrelin is a hormone that is produced in the stomach lining, as well as the pancreas, that has a wide variety of effects. Chiefly, ghrelin is produced to stimulate appetite when we need food, but excess secretion of the hormone would drive appetite unnaturally, as well as affect mental function, memory, increase the concentration of the neurotransmitter dopamine in parts of the brain, promote intestinal wall cell proliferation and increase bowel motility, and affect the immune responses in the intestines. Chronically elevated ghrelin may be associated with GI dysfunction, such as irritable bowel syndrome, increased colon and pancreatic cancer risk, and poor short term memory, as well as having effects on mood. Stomach dysfunction may play a part in ghrelin imbalance, as well as increased oxidative states and inflamamtory dysfunction. Once again, a holistic approach to health in treating sleep apnea may work to resolve these various health problems in each individual case to restore balance and homeostasis, eventually decreasing fatty tissue accumulation and obstructive sleep apnea. This approach will work with long-term improvement in overall health, and the Complementary Medicine physician can help the patient improve these various aspects of their health to eventually cure the underlying cause of sleep apnea.

Metabolic Syndrome is a complex problem that is more fully explored in another article on this website. When this metabolic imbalance worsens in the body, increased stress is created on the metabolic processes, and insulin resistance, weight gain at the midsection, and poor liver metabolic function may result. If the liver is too stressed, triglyceride levels will be abnormal on blood tests, and cholesterol and lipoprotein levels, as well as circulating blood sugars may also be off. Insulin is a steroid hormone, and thus is part of the endocrine system and affected by other hormonal irregularities. This is perhaps one reason we see a higher incidence in women of sleep apnea, especially during the period of perimenopause to postmenopause. Restoration of hormonal balance with holistic treatment may have a very positive effect in the long term on sleep apnea disorder.

Metabolic syndrome is highly associated with estrogen dominance and relative deficiency of progesterone. Research in recent years has found that estrogen dominance with progesterone deficiency is highly associated with metabolic syndrome and insulin resistance. This problem may be worsened with the use of synthetic estradiol and progestins (see research cited below), with a high association between excess circulating estradiol and metabolic syndrome. These drugs may also affect the regulation of inflammation in the body, which could have a direct relationship to tissue hypertrophy in the airways. Studies have found that synthetic progestins exert a negative effect on the level of circulating adiponectin, and disequilibrium between proinflammatory cytokines (high interleukin-6/C-reactive protein) and the anti-inflammatory adipokine (low adiponectin). Since this inflammatory modulation is important in low-grade inflammatory states of fatty tissues, such an imbalance could promote tissue hypertrophy, leading to obstruction airways. The link between these various problems is becoming more and more evident over time.

Countering the health risks associated with chronic sleep apnea

Besides reducing sleep apnea and working to correct the underlying health problems that cause the central and obstructive sleep apnea, the patient with sleep apnea should consider a holistic regimen to protect against the serious health problems associated with the disorder. Cardiovascular risk is the main concern. Much research has uncovered the mechanisms by which increased cardiovascular risk is generated by sleep apnea disorders, and the smart patient seeks to understand the connection and do what is necessary to decrease the risk. Study at Columbia University (cited below) has concluded that obstructive sleep apnea (OSA) directly affects the vascular epithelium (lining of the arteries) by promoting inflammation and oxidative stress while decreasing nitric oxide (a vasodilator) availability and repair capacity of the blood vessels. Expression of the inflammatory mediators COX-2 (cyclooxygenase enzyme) and nitrotyrosine was found to be five-fold greater in sleep apnea patients in study, and nitric oxide synthase was found to be 56% greater in OSA patients than in control subjects. This contributes greatly to the poor health of the arteries, and to accumulation of plaque, or atherosclerosis.

A variety of therapies in Complementary Medicine offer the patient safe and effective therapies to increase antioxidant effects, increase healthy inflammatory regulation, inhibit COX-2, increase nitric oxide bioavailability, and modulate the systems responsible for maintenance and repair of vascular endothelium. Often, these various effects are combined in an herbal formula. Herbs contain a variety of medicinal chemicals, and a formula of herbs contains a wide variety of medicinal chemicals to achieve a complex goal. These chemicals have been well documented and studied, and comprise the modern science of herbal medicine and phytopharmacology. Naturopathic medicine also provides a wealth of research that is ongoing that addresses therapeutic protocol with nutrient medicines. While these therapies can be complex, they generally work to achieve the goal of reestablishing a healthy mechanisms within the body, and restore the homeostatis that protects against cardiovascular risk, and do not require chronic use of the herbs and supplements like pharmaceutical medicines.

Another focus of research into the cardiovascular negative effects seen in obstructive sleep apnea patients is the reduction of blood flow in the brain and increased reactivity to lowered blood pressure, which increases the risk of an eventual stroke, especially in the aging population. Sleep apnea is highly associated with increased stroke risk, and not only the decrease in healthy maintenance of the arterial vessels, but also neurochemical imbalances created in sleep apnea, either as a result of sleep apnea, or perhaps as part of the cause of sleep apnea, are implicated in the increases stroke risk. A study at Yale Center for Sleep Medicine, Yale University School of Medicine, found that there was a consistent decrease in cerebral blood flow velocity in sleep apnea patients during the waking hours, with an slower cerebrovascular response to hypotension. This slow response to hypotension was not attributed to a slow response to increased CO2 in the blood, which occurs when apnea results in decreased oxygenation and increased clearing of carbon dioxide by decreased breathing. The cause of the slow reactivity to hypotension and subsequent exagerrated response occurred because of other chemical imbalances associated with the sleep apnea disorder.

Nitric oxide (NO) is a potent vasodilator and important modulator of cardiovascular health and blood pressure. NO balance is intricately tied to the balance of oxygen and carbon dioxide in the body, as well as to oxygen radicals, or oxidants. Sleep apnea therefore has a clear effect on this oxygen metabolic balance. Red blood cells take up and carry oxygen, and sleep apnea has been shown to affect the oxygen concentration in red blood cells, mainly because of the imbalance of these various oxygen gases. A number of chemicals in the body are important as bioreactants and precursors to nitric oxide metabolism. Thees include glutathione, our main antioxidant and detox chemical, Cysteine, nitrates that are absorbed from food in our small intestine, L-arginine, and the various Vitamin B3 metabolites, or niacin molecules. As stated, there is a stress on the body in sleep apnea that leads to poor bioavailability of nitric oxide and increased nitric oxide synthase as a response. Nutrient and herbal medicine offers sound research and treatment to address such concerns.

Serotonin & Other Neurotransmitters, the role of chemical imbalance in the pathology of comples sleep apnea

The neurotransmitters serotonin and norepinephrine (adrenaline) play an important role in the body and mind, and imbalance of these chemicals has been associated with sleep apnea and various negative health consequences of this disorder. Many anti-depressant and anti-anxiety medications have been created to achieve a higher level of these neurotransmitters in the brain tissues, such as Prozac, Cymbalta, Effexor etc. Many patients fear that chronic use of these SSNRIs have preceded the onset of sleep apnea, and are associated with the central pathology. Health experts have countered that SSNRIs could not cause sleep apnea because they actually reduce REM time, or deep sleep, the period that sleep apnea occurs. The analysis of central sleep apnea is still confounding researchers, though, and such simplistic reasoning is being questioned. There is a big problem with the limited effectiveness of the anti-depressants, as well as a big problem with an addictive cycle, as patients often have severe symptoms when trying to go off of these drugs. Many psychopharmacologists are also concerned that chronic use of SSNRIs are creating a greater usage of available serotonin and norepinephrine in the brain by blocking reuptake, but do not address the deficiencies and imbalances. Many doctors are now prescribing 5HTP and other nutrient and herbal supplements along with the drugs to try to reestablish a greater bioavailability and feedback balance of neurotransmitters in the brain.

Serotonin is created in the cells of the body, throughout the body and brain, from the amino acid tryptophan. L-tryptophan is an essential amino acid, meaning that it must be obtained from the diet and cannot be adequately manufactured in the body. Use of L-tryptophan by physicians has achieved great success in the treatment of depression and anxiety, and is used by many psychiatrists when their patients prove resistant to the serotonin reuptake inhibitors commonly prescribed. Serotonin, dopamine and norepinephrine are neurotransmitters that may also play a significant role in the mechanisms of central and complex sleep apnea disorders. Serotonin, tryptophan, and the precursor 5HTP (5-dydroxytryptophan precursor), are part of a metabolic mechanism associated with maintaining the right levels of the neurohormone melatonin. While melatonin was associated mainly with the sleep cycle in the past, research in recent years has uncovered its powerful effects throughout the body, its potent antioxidant activity in the brain, and its relationship to the diurnal hormonal metabolism.

High levels of circulating catecholamines, or neurohormonal mediators secreted by the adrenal gland, are associated with sleep apnea. Chronic stress may induce a condition called adrenal fatique, and levels of adrenal mediators, called adrenaline in the past, and now referred to mainly as norepinephrine and cortisol, are not maintained at proper levels in a diurnal cycle (night/day). Sluggish adrenal response will often create a situation of excess cortisol during the night, causing insomnia, non-restful sleep, and anxiety, and depressed cortisol levels during the day, causing sluggishness, fatique, and slow mental response. This upset of the diurnal neurohormonal balance may have a direct as well as indirect effect on sleep apnea. Clinical adrenal pathology, such as pheochromocytomas, produce excess catecholamines and are highly associated with sleep apnea. In a similar way, subclinical adrenal fatique syndromes may also be integral to the complex pathology.

Research in 2007, cited below, revealed that excessive catecholamines have been noted in patients prescribed antidepressants. Tricyclic antidepressants and phenoxybenzamine are most implicated, but selective serotonin and norepinephrine reuptake inhibitors (SNRIs) have now also been implicated in cases of medication induced high catecholamine levels, which are noticed as false positives on tests for phiochromocytomas. 40% of these false positive results of tests for adrenal tumors are attributed to these drugs. The implications are that chronic use of these antidepressants may be indirectly associated with sleep apnea disorders, and that imbalances related to serotonin, norepinephrine, and melatonin may be central to the causative mechanisms of sleep apnea. Restoration of a natural balance of catecholamines may have a positive effect on sleep apnea. Use of natural precursors and other chemicals that help achieve a bioavailability of these neurotransmitters is an alternative to synthetic drugs that block reuptake etc. Many patients have found success by holistic restoration of health and by establising a health bioavailability of the chemistry needed for your system to achieve proper balance.

One novel therapeutic supplement now being used is a low dose combination of Vitamin B6, 5HTP, St. John's Wort, and melatonin. These four supplements act synergistically to allow your brain to better regulate the diurnal and feedback levels of neurohormones and neurotransmitters in the brain. The goal of such therapy is to eventually restablish a healthy balance and homeostasis.

Some novel therapeutic aids used to reestablish a healthy bioavailability of neurotransmitters are listed here:

Vitamin B6 is needed to produce serotonin. 5HTP from griffonia seed is a precursor to L-tryptophan and is able to cross the blood brain barrier to enter the brain tissue. Tryptophan is found in the foods oats (steel cut unprocessed), bananas, dried dates, milk, yoghurt, cottage cheese, red meat, eggs, fish, poultry, sesame seed, chickpeas, sunflower seeds, pumpkin seeds, spirulina and peanuts. It may also be taken as an amino acid supplement, or tryptophan precursor 5HTP (extracted from griffonia seeds) may be taken to increase bioavailability in the brain. Tryptophan is a complex carbohydrate with nitric oxide added. Increased or decreased nitric oxide may have implications on the bioavailability of tryptophan amino acid as an available precursor to serotonin or melatonin in the brain. L-Arginine is an amino acid that is a precursor to the healthy formation and bioavailability of nitric oxide. The steady-state bioavailability of nitric oxide is determined by both its rate of formation and its rate of decomposition, and a number of chemicals contribute to a better nitic oxide metabolism in the brain and arterial tissues. Antioxidants such as superoxide dismutase have been shown to protect nitric oxide availability in the arterial endothelium, and increased concentration of free radical oxidants has been shown to decrease the nitric oxide availability. Niacin and niacin metabolites have been shown to aid nitric oxide bioavailability, and thus have been a benefit to cardiovascular health as well. Melatonin is a hormone that is related to serotonin and is secreted in the diurnal cycle (day-night) to affect sleep cycles and hormonal balance in the diurnal cycle. There is a strong system of balance, or homeostasis, that the brain tries to maintain, and to promote this healthy balance, a number of factors may need to be addressed with nutrient and herbal medicine. The neurohormones GABA and dopamine are also related in this balanced equation. In addition, melatonin is a key antioxidant in the brain.

New research is revealing how the body regulates fatty accumulation in muscles, and will lead to a more specific targets for herbal and nutrient medicine

Increased fatty accumulation and tissue growth is the most direct cause of obstructive sleep apnea. What causes this fatty accumulation and growth is rarely discussed with the patient, but this is a key consideration when trying to reverse chronic sleep apnea. Besides insulin and adiponectin, there are a variety of growth factors that are related to such tissue hypertrophy.

A study completed by the Swedish medical university Karolinska Institutet in 2010, and published in the scientific journal Nature, shows that hormonal signalling from muscles via the VEGF-B protein hormone (vascular endothelial growth factor) allows increased fatty acids to be transported throught the blood vessel membranes to be utilized by the muscles for energy. VEGF-B signalling created more fatty acid transport proteins in the blood vessel walls, and normally these fatty acids would be utilized by the muscles for energy. In animal studies, subjects that lacked VEGF-B expression in the muscles or VEGF-B receptors in the blood vessel walls had difficulty transporting fatty acids to the muscles and instead these fatty acids accumulated in white adipose tissues, the fat cells that are implicated in insulin resistance. VEGF expression in the muscles increases when the muscle is not receiving sufficient oxygen, triggering increased blood vessel formation. VEGF-B is a member of this family of molecules that does not respond to oxygen insufficiency, or hypoxia, directly, but is affected by VEGF stimulation. Binding of VEGF-B to the receptors on the blood vessel walls triggers a response that is also shared by the inflammatory mediators in the body, the tyrosine kinase pathway, and there is a close relationship between various inflammatory mediators, that also respond to hypoxia, and VEGF, as well as a protein hormone called platelet-derived growth factor. As research continues into this complex cascade of chemicals, we will gain an increased understanding of the holistic mechanisms that result in the accumulation of fatty tissues in airway muscles. All of this research reveals the complex workings of the body, and the need to target multiple systems and holistically promote a healthier homeostatic metabolism.

Another VEGF protein has been the subject of much research in cancer studies. VEGF-A is linked to tumor growth and the stimulation of increased blood vessel formation in tumors to meet the high energy needs. A number of pharmaceuticals have been created to inhibit VEGF formation, including Avastin. Naturopathic medicine has researched natural nutrient chemicals to achieve, or help achieve these goals, without side effects. This research may be important in the treatment of pathological fatty accumulation in muscle tissue. IP6 is one of these therapeutic nutrient medicines studied. Inositol hexaphosphate is found in high fiber foods, and has been proven in scientific studies to inhibit tumor growth via inhibition of VEGF production, as well as exerting strong antioxidant effects. Such effects will probably be found to also affect VEGF-B overexpression, and may be an effective addition to holistic and integrative therapy to reduce fatty accumulation in obstructive sleep apnea.

Another area of naturopathic research that may relate directly to inhibition of fatty accumulation in muscles is the subject of advanced glycation endproducts, or AGEs, that are implicated in the poor health of blood vessel walls and the accumulation of plaque and development of atherosclerosis. AGEs are also implicated in the physiological dysfunctions related to insulin resistance and metabolic syndrome, and the A1C index is now highly utilized in the diagnosis of diabetes type 2, or metabolic syndrome. AGEs could be implicated in the problems with VEGF-B signalling in the blood vessel walls, resulting in increased fatty acids transported to white adipose tissues rather than muscles for conversion to glucose energy. A number of nutrients have been studied in relation to improved fatty acid metabolism and clearing of AGEs. One company, Vitamin Research, has combined these nutrients and herbs into a product that includes R-Lipoic Acid, P5P, L-Carnosine, L-Histidine, N-Acetyl-Cysteine, Benfotiamine, and Guava and Yerba Mate leaf extracts. While this prescription is recommended for arterial health, macular degeneration and neurodegenerative conditions, future research may find this nutrient medicine formula very helpful in fatty tissue accumulation in obstructive sleep apnea in the future.

VEGF-B is also related to various inflammatory mediators, both in pathways that stimulate expression, and in sharing of receptors. Chronic low-grade inflammatory states may eventually have much to do with dysfunction of the VEGF-B metabolism and pathway. VEGF and interleukin-8 (IL-8) have been linked in studies, and problems with VEGF expression or receptor function could relate to excess IL-8, which is a pro-inflammatory mediator in epithelial and endothelial cells, and secreted by neutrophils and lymphocytes. Allergic responses in the airway could be related to eventual dysfunction of the VEGF-B pathway, as well as chronic tissue inflammation related to myofascial problems. A thorough approach to treatment of obstructive sleep apnea may include therapy that resolves myofascial problems, clears tissues of irritants and fibrin accumulations, and stimulates an improved immune response. When a number of interrelated health problems may work together to create an eventual complex pathology, such as fatty tissue accumulation in the airway creating obstructive sleep apnea, the therapeutic protocol must sometimes address these problems in a more complex manner. Complementary Medicine offers such holistic and intensive approaches with relatively inexpensive therapy. The end result of such therapy may be the eventual resolution of the causes of sleep apnea, as well as much improvement in overall health.

Information Resources

A 2010 article in the Journal of Clinical Endocrinological Metabolism, supported by research at the Hospital de Bicetre in France, found that endocrine and metabolic disorders have a high association with sleep apnea, and that in some cases, the sleep apnea was cured or improved by treatment of the endocrine disorder, and that an approach with Complementary Medicine integrating various therapeutic protocols is recommended:http://www.ncbi.nlm.nih.gov/pubmed/20061419?dopt=Abstract A 2008 article published in Diabetes Care, and supported by research at the Sleep Lab, Meyer Children'a Hospital, Haifa, Israel, finds that obstructive sleep apnea and metabolic syndrome are intimately linked, with each worsening the other, and highly associated with insulin resistance and autonomic imbalance: http://www.ncbi.nlm.nih.gov/pubmed/18227501 A 2008 article published in the Archives of Physiology and Biochemistry, researched by the Sleep Research and Treatment Center in Hershey, Pennsylvania, found that insulin resistance and elevated insulin was associated with sleep apnea independent of obesity, and that subclinical hypothalamic function deficiency plays a major role in the pathogenesis of sleep apnea: http://www.ncbi.nlm.nih.gov/pubmed/18946782 A 2006 study at the Center for Clinical and Basic Research, Ballerup, Denmark, found that metabolic syndrome and insulin resistance was linked to estrogen/progesterone imbalance, and that prescription of synthetic estradiol and progestins should only be prescribed when necessary for these patients; progestins have been shown to decrease circulating adiponectin, which is linked to inflammatory dysfunction that could be responsible for tissue hypertrophy, low grade chronic inflammation, and thus obstructive sleep apnea due to tissue growth: http://www.ncbi.nlm.nih.gov/pubmed/16766431 A 1998 study at the Clinical Pharmacology and Metabolic Research Unit, University of Vermont, found that synthetic hormone replacement therapy was responsible for many cases of increased midsection fat accumulation, as in metabolic syndrome. The association with these fat metabolism changes and the fatty growth of tissues in obstructive sleep apnea are now well documented: http://www.ncbi.nlm.nih.gov/pubmed/9847982 A 2002 study at the University of Wisconsin School of Medicine and Public Health found that chronic use of inhaled corticosteroid, such as asthma med inhalers, had a high association with risk of acquiring obstructive sleep apnea:http://chestjournal.chestpubs.org/content/135/5/1125.abstract A 2007 study at the Royal Bournemouth Hospital in England found that antidepressant medications may be implicated in many cases of elevated adrenal neurohormones, or catecholamines, which have a high association with central sleep apnea:http://www.endocrine-abstracts.org/ea/0014/ea0014P482.htm Study at Penn State University College of Medicine found a high association between obstructive sleep apnea, insulin resistance, hypercytokinemia (hypersensitive immune response), polycystic ovary syndrome, and the hormonal imbalances associated with the premenopausal state, independent of obesity:http://www.ncbi.nlm.nih.gov/pubmed/11158002?dopt=Abstract The strong connection between childhood sleep apneas and central adrenal insufficiency in Prader-Willi syndrome implies that there is a connection between adult sleep apnea and adrenal fatique and hormonal imbalance: http://www.ncbi.nlm.nih.gov/pubmed/19383777 Adrenal fatique is explained clearly in this articel published by Complementary Prescriptions: http://www.cpmedical.net/articles.aspx?page=LIST&ProdID=6627&zTYPE=2 Studies at Stanford and the University of Wisconsin show that sleep deprivation consistently resulted in hormonal changes (reduced leptin with increased ghrelin) that resulted in poor appetite control and weight gain:http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0010062 An article in Respiratory and Critical Care Medicine from 2004, states unequivocably that sleep apnea and metabolic syndrome are strongly associated independently from obesity:http://ajrccm.atsjournals.org/cgi/content/full/169/2/139 In 2009, research in Australia found that progesterone/estrogen balance affects insulin sensitivity (resistance) through modulation of adiponectin and body fat, and that fatty tissue accumulation (as we see in obstructive sleep apnea) is controlled by adiponectin hormone in balance with other hormonal mechanisms: http://www.ncbi.nlm.nih.gov/pubmed/19154958 A 2008 study at the Columbia University College of Physicians and Surgeons and Tulane University School of Medicine found that sleep apnea is associated with high cardiovascular risk by promoting inflammation and oxidative stress while decreasing nitric oxide availability and vessel reapair capability:http://circ.ahajournals.org/cgi/content/short/CIRCULATIONAHA.107.741512v1 A study at the Yale Universisty School of Medicine Center for Sleep Medicine found that sleep apnea patients had decrease waking cerebral blood flow and slow response to hypotension that could account for the increased risk of stroke:http://jap.physiology.org/cgi/content/full/105/6/1852 A study at the Karolinska Institue in Sweden in 2010 found that pathological fatty accumulation in muscles, such as we see in obstructive sleep apnea, is related to a hormonal protein called VEGF-B (vascular endothelial growth factor), and that with insulin resistance and metabolic syndrome, a dysfunction is created that uncouples fatty acid burning in the muscle to meet energy needs, and the signals for transport, creating accumulation of fatty acids in the white fat cells that goes unused:http://www.nature.com/scibx/journal/v3/n13/full/scibx.2010.394.html An article in the Clinical Cancer Research journal in 2001 explored the research that has found a strong link between inflammatory mediators and the expression of VEGF, pointing to the complex holistic relationship between immune modulation and hormonal control of fatty tissue metabolism: http://clincancerres.aacrjournals.org/content/7/2/435.full A randomized clinical study in 2008 at Justin-Liebig University Geissen, Germany, of the effects of a low dose of valerian and hops showed significant benefit to relieve insomnia over placebo. The study used EEG to evaluate the sleep cycle and brain activity, noting improved sleep cycle: http://www.ncbi.nlm.nih.gov/pubmed/18559301