Board-certified in General Preventive Medicine and with a graduate degree in public health, Dr. Ingrid Kohlstadt became convinced that nutrition is powerful and underutilized in preventing disease. She therefore focused her career on nutrition through fellowships at Johns Hopkins and The Centers for Disease Control and Prevention. She worked as a bariatric physician at the Johns Hopkins Weight Management Center and the Florida Orthopaedic Institute.
Following is an article written by Dr. Kohlstadt in which she discusses various roadblocks to getting good quality sleep as well as addresses potential solutions:
By Ingrid Kohlstadt
Introduction
When asked, “Doc, what can I take to…lose weight, improve my sports game, treat my diabetes, etc,” I am increasingly dispensing an often overlooked treatment. “Take a nap. Or better yet, get a good night’s sleep.”
Two hundred years ago Americans slept an average of two hours more per night. The light bulb may be the invention which has most contributed to our modern society’s collective sleep debt. Being too busy is often cited as the key reason for too little sleep. As a parent of young children I can wholeheartedly empathize. However, many people are unable to get a good night’s sleep, even when they have the time. That’s where nutrition can help repair the “transmission.”
Treat sleep apnea and pain
Both the public and practitioners are more aware of obstructive sleep apnea today than they were a few decades ago. Still the diagnosis, especially among overweight children, can be subtle. Once diagnosed, some people have been told to lose weight and then their sleep apnea will resolve. Clinically speaking, it’s the other way around! Treating sleep apnea helps weight loss. Apnea raises blood pressure and adversely affects insulin control making weight loss metabolically more difficult, not to mention the obvious that if you are tired from poor sleep it is difficult to exercise and prepare healthful food. If instead you correct sleep apnea first, weight loss becomes a successful endeavor. …and of course, nothing succeeds like success.
Pain can create a vicious cycle of sleep deprivation. Whether the pain arises from orthopedic injury, arthritis, headache, fibromyalgia or any number of other causes, it can make both falling asleep and staying asleep difficult. In turn, sleep deprivation exacerbates the pain.
Difficulty sleeping in general
Many people with difficulty sleeping don’t have a medical condition with a labeled diagnosis. Their difficulty sleeping is just as much a hindrance to their overall well-being, but the path forward is less clear. Often patience and persistence pay off and help usually comes in the form of rebalancing neurotransmitters.
Restless leg syndrome is nighttime calve pain often associated with low iron status and smoking. Increasing the neurotransmitter GABA can reduce symptoms along with treating any underlying medical cause.
Dyssynchronosis is “working against the clock.” The neurotransmitters and hormones are less effective when their circadian pattern is altered. Jetlag and shift-work are examples, but smaller disturbances such as the semiannual time change and a celebratory weekend can also have this effect.
Caffeine consumption changes neurotransmitter balance. Hidden sources include medications, beverages, mints and candies. Also under-recognized is that a phytonutrient found in grapefruit juice can delay the breakdown of caffeine in the body, in effect doubling the potency of a cup of coffee.
Medications, especially those which act in the brain to improve mood or cognition, alter the balance of neurotransmitters. They may not promote or antagonize the neurotransmitters most involved in sleep, but when one neurotransmitter’s concentration or activity changes, the whole balance of brain chemistry is altered by mechanisms which science is now elucidating.
Dieting can lead to difficulty sleeping by causing the body to use protein for energy rather than for repairing protein structures such as neurotransmitters. Neurotransmitters are made from amino acids, protein building blocks which, unlike the neurotransmitters themselves, can cross the blood brain barrier and enter the central nervous system.
Stress, referred to in Shakespeare’s Macbeth as “the raveled sleeve of care,” changes the brain’s neurotransmitter balance. Over time, stress depletes nutrients needed to maintain healthful brain functioning and can create a stress-sleeplessness cycle.
Nutritional support
Over-the-counter and prescription sleep aids are a sleep band-aid, usually covering up poor sleep quality with sleep quantity. They do little for the underlying nutrient deficiencies and neurotransmitter imbalances which disturb sleep quality. This prompts the question, what can help support sleep?
Herbs have been used to help achieve sleep throughout history. However, not all are safely prepared, and many don’t mix well with modern medicine. That said, the herb German chamomile (Matricaria recutita) appears safe for use as a sleep aide. Science isn’t quite sure how this herb exerts its calming effects, but appears to bind to benzodiazepine receptors in the central nervous system. Theanine, an amino acid found in green tea, may act similarly.
5-HTP is an amino acid precursor to serotonin. I have found 25-50mg of 5-HTP taken as a dietary supplement to be supportive of restful sleep, especially when taken 30-60 minutes before bedtime on an empty stomach. Anyone on a medication which increases the activity of serotonin, such as serotonin reuptake inhibitors (SSRIs), should not take 5-HTP concurrently. However, 5-HTP merits consideration afterwards to ease the symptoms associated with discontinuing an SSRI.
Vitamins B6 and B12 are active in the brain where they are involved in converting 5-HTP into serotonin. The same vitamins can be depleted by medications and stress, therefore, supplementation is often recommended.
Minerals are active in the brain and work alongside neurotransmitters. Since they are present in amounts often too small to measure, their roles are poorly studied. Magnesium is important in helping muscles (including muscles of the bowels) relax, and exerts a calming effect in the brain as well. Supplemental magnesium is only beneficial when the body’s magnesium stores are suboptimal. That said, modern diets, calcium supplements and several different classes of prescription medications reduce magnesium stores suggesting that many people may derive sleep benefit from daily low-dose supplementation.
Brain cells have lots of mitochondria for energy synthesis. The function of mitochondria and other membrane rich structures in the neurons depend largely on the composition of the membranes. A diet rich in choline, phosphotidyl serine, and essential fatty acids is improves the functioning of the membranes.
Conclusion
Most medical conditions which contribute to sleep deprivation are associated with neurotransmitter imbalances and suboptimal vitamin levels. Taking an over-the-counter antihistamine or a prescription sleep aid generally doesn’t correct the underlying metabolic disturbance and therefore is unlikely improve sleep quality.
So where can patients who toss and turn, turn for nutritional support? One such resource is http://www.warmglassofmilk.com/. The fun and relaxing website reviews sleep hygiene basics and offers a dietary supplement intended to repair the sleep engine’s neurotransmission.
Ingrid Kohlstadt MD, MPH, FACN has been elected a Fellow of the American College of Nutrition and is an associate at the Johns Hopkins School of Public Health. She is the founder and chief medical officer of INGRIDients™, Inc., which provides medical nutrition information to colleagues, clients, and consumers. She is employed at the Food and Drug Administration, Office of Pediatric Therapeutics.
Dr. Kohlstadt is a graduate of Johns Hopkins School of Medicine, Class of 1993. She earned her bachelor’s degree in biochemistry at the University of Maryland and as a Rotary Club scholar at Universität Tübingen, Germany in 1989.
As a congressional intern and later with the FDA, USDA, health department, USAID, and United States Antarctic Program, Dr. Kohlstadt studied the rugged terrain of health policy, specifically how food and nutrients can be incorporated into primary care medicine. These experiences served as a basis for editing Food and Nutrients in Disease Management (CRC Press, Boca Raton, FL, 2009) and Scientific Evidence for Musculoskeletal, Bariatric, and Sports Nutrition (CRC Press, Boca Raton, FL, 2006). Both texts are developed by large forums of medical experts and are intended for health care practitioners, informed patients, and policy-makers.
