Category Archives: sleeping pills

Sleep! You can’t live without it.

31 Replies

Circadian rhythm refers to the cycling of hormones according to the time of day. Every hormone cycles with daylight and darkness, each in it’s own way. Our brain has a master clock, called the circadian clock, controlled by specialized cells deep in the brain. There is a direct connection from our retina (in the back of the eyes) to the circadian clock in the brain. Blue light (part of the normal outdoor spectrum of light) stimulates very specific receptor cells in the retina which in turn communicates directly with the circadian clock telling the brain whether it is day or night. To synchronize our hormones and achieve restorative sleep, we must get outdoor light exposure to our eyes (without sunglasses, early in the day) and limit light exposure in the evening.

Artificial light, especially from cell phones and other devices that emit intense blue light, shift work, late night social activity, poor eating habits, sedentary lifestyle and at the opposite extreme, late evening workouts,  can all disrupt our circadian rhythm preventing adequate restorative sleep. A rare genetic illness called fatal insomnia that strikes adults at middle age prevents sleep and results in death within a few months, highlighting the importance of sleep. Sleep deprivation can kill a human quicker than starvation! Adequate amounts of deep non-REM sleep are required for tissue regeneration, healing, DNA repair and immune function. REM sleep with dreaming provides great benefit by organizing our memory, discharging the emotional content of traumatic events, and facilitating creative brain activity. One night of short-sleep produces a state of inattention and slow reflexes as dangerous as driving under the influence of alcohol intoxication. Chronic  short sleep and disrupted circadian rhythm results in increased risk of depression, cancer, hypertension, diabetes, dementia, obesity, metabolic syndrome, insulin resistance, heart attack and stroke, to name a few. Sleep interruption immediately halts weight loss during a calorie restricted diet (likely the result of hormonal disruption). So getting an adequate amount of restorative sleep every night is essential to good health. Here a few tips to help achieve a good night’s sleep each and every night.

  1. GET OUTDOOR LIGHT EXPOSURE ON YOUR EYES WITHOUT SUNGLASSES EVERY DAY, EARLY IN THE DAY. This helps set your biologic/circadian clock. Even on a cloudy day, outdoor light is much stronger and natural than indoor light. It is essential for setting your biologic/circadian clock. If you cannot get outside, stand or sit in front of a large window for 20-30 minutes in the morning, looking outside. Take a lunch break outside without sunglasses. Wear a shade hat instead of sunglasses. Your brain needs to experience natural outdoor light during the day.
  2. Avoid bright light in the evening, especially the light from TV, computer screens, cell phones, which all emit intense blue light and trick your brain into thinking it is daytime. Wear blue light blocking glasses/goggles for 2-3 hours before bed. (Amber tinted glasses which block blue light can be purchased on-line and can be worn over reading glasses) There is also software available that will decrease the blue light intensity of computer screens and cell phones in the evening.
  3. Practice time restricted eating. Limit all eating to an eight hour period, thus providing for an over-night fast of 16 hours. If that does not seem possible try to limit eating to a 10-hour period which provides a 14-hour overnight fast. This improves sleep, circadian rhythm, blood pressure, blood sugar and reduces stress hormones. NO SNACKS BETWEEN MEALS. NO FOOD FOR 2 HOURS BEFORE BED. For every hour decrease in eating time period from 12 hours to 8 hours you get health benefit.
  4. Eat an anti-inflammatory diet.
  5. If you snore, are overweight/obese, fall asleep during the day, or do not feel refreshed in the morning ask your doctor to order a sleep study. Obstructive Sleep Apnea makes restorative sleep impossible and increases risk of heart attack, stroke and most chronic diseases.
  6. Avoid alcohol altogether and avoid caffeine after late morning.  Alcohol in the evening may help you fall asleep but it results in a withdrawal from alcohol during the night. This disrupts normal sleep patterns.
  7. Sleep in a cold, dark, quiet room. Use black-out curtains, no night lights, no phone charger lights, no lights of any kind should be on in the room. Any amount of light in the room impairs the production of melatonin which facilitates sleep onset.
  8. Have a wind–down time every evening. Develop habits of non-stressful activities, soft music, dim light, casual conversation, enjoyable reading. Do not spend evening time dealing with finances, conflict, or emotional activity.
  9. Try a magnesium supplement before bedtime. Magnesium glycinate, magnesium citrate, magnesium gluconate, are absorbed much better than cheaper supplements such as magnesium oxide. Magnesium L-Threonate is expensive, but it crosses the blood brain barrier into the brain with the greatest brain penetration of all magnesium supplements.
  10. Manage stress with yoga, meditation, regular exercise (but no intense exercise in the evening.) Perform most of your exercise outdoors in a green space. This provides much more health benefit than the equivalent exercise indoors.
  11. Regular contact with supportive family and friends is essential to health and reduces stress. The greatest predictor of health vs disease is the amount of social connectedness an individual experiences.
  12. Establish regular wake-up times and go-to-bed times. Regular sleep habits are essential. If you must rely on alarm clocks you do not have good sleep habits.

A few words about alcohol, caffeine and sleeping pills.

A drink or two in the evening may help you relax but it disrupts your sleep by causing a mild episode of alcohol withdrawal as your liver metabolizes the alcohol and your blood levels drop. Even this slight degree of alcohol withdrawal will impair a good night’s sleep.

Caffeine impairs sleep by blocking adenosine receptors in the brain. Adenosine is the neurotransmitter that increases gradually during the day creating a sate referred to as sleep pressure. Some people metabolize caffeine quickly, others slowly. The slower you metabolize caffeine the longer it takes to clear it from your adenosine receptors. Without adequate sleep pressure (adenosine receptors filled with adenosine in the brain) you cannot fall asleep. Many sleep experts recommend complete abstinence from caffeine and suggest that if you need caffeine to get started in the morning you are regularly sleep deprived.

Sleeping pills of all kinds interfere with normal sleep architecture. While they facilitate falling asleep, they impair your ability to achieve deep restorative stages of sleep and can produce many undesirable side effects including addiction, withdrawal symptoms, sleep walking, sleep driving, worsening of asthma and COPD, constipation, diarrhea, daytime drowsiness, burning and tingling sensations, unusual dreams, weakness, heartburn, etc…. Most importantly they all interfere with cycling through the various stages of sleep in a normal, restorative pattern!

If you want to explore these concepts in depth here are two excellent books that discuss sleep and circadian rhythm.

Why We Sleep, by Matthew Walker Ph.D.

The Circadian Code, by Satchin Panda Ph.D.

Eat clean, sleep well, spend time exercising out of doors, love one another.

Bob Hansen MD

Over-diagnosis and Over-treament, Less is sometimes more

Leave a reply

There have been many books published recently by physicians concerned about over-diagnosis and over-treatment. One very emotional area that caused great controversy when new prevention guidelines were published (regarding mammograms) relates to early detection and treatment of cancer. It would seem intuitively obvious that early detection and early treatment of cancer would save lives but it turns out this is not always so straight forward. Some cancers are very slow growing and early detection and treatment can cause more harm than good. This has been argued relative to screening for breast cancer, cancer of the uterus and prostate cancer, among others. For these particular cancers the screening tests are mammograms, pap smears and PSA blood test. To understand how and why less could be better you should read  Overdiagnosed.

If a cancer is diagnosed by a screening test 3 years before symptoms would have resulted in a diagnosis, but the early treatment does not change the course of the illness compared to treatment latter, it gives the appearance that the patient lived three years longer as a result of early treatment simply because the patient carries the diagnosis for three years longer. This actually turns out to be the case in many situations. Despite this knowledge our emotional response as physicians and as patients refuses to adapt to new data and we continue to follow old habits such as annual pap smears even though the data suggests that pap smears every three years would be equally  effective in saving lives and would actually prevent unnecessary, expensive and anxiety producing follow up procedures and testing. The exception to this recommendation would be for “high risk” individuals that still benefit from more frequent screening.

It turns out that in the US we likely over-diagnose and over-treat many conditions. The benefits of treatment are sometimes not justified by the side-effects and complications of the treatment. As a result of this concern the  Choosing Wisely campaign was created by a consortium of more than 30 Medical Specialty Societies with a goal of avoiding unnecessary testing and treatment. This is similar to the   Too much medicine campaign | BMJ

Medical testing can cause harm directly (complications of the test itself) but also indirectly. False positive results can lead to further invasive testing which can have complications and create anxiety for the patient.

Beyond screening tests for patients without symptoms there are many drugs now being marketed to treat “conditions” that may not need treatment. (read my posts on statins as an example) Big money is behind over-treatment and it is hard to stem the tide. Dr. Malcolm Kendrick | Scottish doctor and author of ‘The Great Cholesterol Con’

The BMJ (formerly the British Medical Journal) has been much more active in addressing these concerns as stated below:

“Has modern medicine undermined the capacity of individuals and societies to cope with death, pain, and sickness? Has too much medicine become a threat to health? Yes, argued Ray Moynihan in a BMJ theme issue in April 2002. He accused the pharma industry of extending the boundaries of treatable disease to expand markets for new products. Barbara Mintzes http://www.bmj.com/content/324/7342 blamed direct to consumer advertising of drugs in the US for portraying a dual message of “a pill for every ill,” and “an ill for every pill.” Elsewhere in the issue, doctors were accused of colluding in and encouraging medicalisation. Leonard Leibovici and Michel Lièvre http://www.bmj.com/content/324/7342/866 wrote : “The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them.”

Useful links:

Treatment of GERD with prolonged use of a Proton-pump inhibitor results in increased risk of pneumonia and increased risk for vitamin B12 deficiency http://jama which can result in permanent nerve damage, anemia and other ailments. This class of drug has many other potential complications. They cause decreased intestinal absorption of minerals and other nutrients and likely alter the mix of important health-promoting bacteria in your gut. They can lead to  Small intestinal bacterial overgrowth in 35% of patients who use them. They also likely contribute to increased risk of osteoporosis,  fractures and a four-fold increase in certain heart  rhythm disturbances. These drugs are now available as non-prescription medications as well as prescription medications and they are often indiscriminately used for prolonged periods of time.

Sleeping pills are another example of over-prescribed medications. The FDA has approved the use of many of these drugs for just a few weeks at a time but I see patients frequently on these medications for years. They can  lead to addiction within a few weeks, can cause dizziness, drowsiness, memory problems, confusion , hallucinations, and other side effects, and should not be used with alcohol. Sleep walking, sleep eating, sleep driving, and other abnormal-dangerous behaviors have been reported with many sleep medications. In addition to these concerns:

“An analysis of data of clinical trials submitted to the FDA concerning the drugs zolpidem, zalepon, and eszopiclone (Ambien, Sonata, and Lunesta) found that these sedative hypnotic drugs more than doubled the risks of developing depression compared to those taking placebo pill. All studies have been funded by the drug companies without independent research.”

Examples such as this abound in the US, the only developed country that permits direct to consumer advertising of drugs on TV.

Why do we pay almost twice per capita for health care in the US compared to other developed countries while ranking between 20 and 30 on various measures of public health? Over-diagnosis and over-treatment in my opinion, are big factors.

I would encourage you to explore some of the links above to learn more about over-diagnosis and over-treatment so that you can make more informed health-care decisions.

Peace

Bob Hansen MD