Blake Graham is a Clinical Nutritionist specializing in nutritional and environmental treatments for patients with CFS, FM, and other chronic conditions. He is an associate of the Australasian College of Nutritional and Environmental Medicine in Perth, Western Australia (AACNEM). This article is reproduced with permission from his website Nutritional-Healing.com.au
Inadequate sleep quantity and quality are well known to cause a variety of different biochemical and physiological changes, and are a key part of the vicious cycle of CFS. It is imperative to do everything possible to optimize sleep quantity and quality.
Everyone with CFS has disordered sleep, many not realizing it. Individuals who appear to get sufficient duration of sleep are still likely to have disordered sleep quality. It is ironic that people who are so exhausted have difficulty falling asleep. “Insomnia” is a condition in which a person has difficulty falling asleep and/or difficulty maintaining sleep.
Treatment Options for Improving Sleep
Most people with CFS require a multifaceted approach to get their sleep under control, rather than a single approach. Conventional “sleep medicine” is one of the areas of medicine which has a strong emphasis on a multifactorial approach.
There is a strong mentality in people with insomnia of looking for the answer in pill form. Most people look straight for these options, skipping past other issues. This is a huge mistake in my opinion, as only part of the answer lies in sleep inducing supplements or medications. These substances can in many cases assist sleep initiation, but sleep quality often remains disturbed.
The following is a discussion of non-drug options for correcting sleep disorders.
1. Remove Medical & Other Causes
There are dozens of different causes of insomnia. People with CFS usually have a vicious cycle consisting of a number of the following causative factors. Individual contributing factors must be identified and treated appropriately.
Hormone and neurotransmitter imbalances. The main causes of insomnia in the CFS population appear to be the changes in neurotransmitters, hormones, and central nervous system function. Over 20 different hormones/neurotransmitters are involved in the regulation of sleep.
Sleep apnea. Sleep apnea is a condition in which a person has episodes in which their upper airway is partially or completely obstructed during sleep. If your partner hears gasping, choking, or snorting noises during the night or you sometimes wake in the night with a snort, gasp, or choking feeling, this is a good sign you may have sleep apnea. The following are risk factors or possible signs/symptoms of sleep apnea:
n Large neck circumference
n Family history of sleep apnea
n Smoking and alcohol use
n High blood pressure
n Unrestful sleep.
Sleep apnea is more common in males and risk increases with age. If your partner snores, have him or her checked for sleep apnea and move to another room until they have eliminated their snoring.
Sleep apnea is generally checked for via a procedure called a sleep study. Another option is the “Sleep Strip” [a four-inch FDA-approved “sleep mustache” device the patient can wear at home during a night’s sleep that screens for apnea (see www.sleep4health.com.au/prodsleepstrip.shtml and www.influ-ent.com/prod03.htm ) ].
Sleep apnea is most commonly treated using a continuous positive airway pressure (CPAP) device which maintains an unobstructed airway during sleep. An alternative treatment used to treat sleep apnea is the “Myofacial Toner” (a small mouth-exercise device, see www.sleep4health.com.au/prodtoner.shtml), which works by strengthening the orbicular muscle of mouth and thereby normalizing the position of the tongue and hyoid larynx. This improves upper respiratory tract function and treats sleep apnea and snoring.
Restless legs syndrome (RLS). RLS is a condition in which uncontrollable movements and sensations in the legs impair sleep duration and quality. The following are possible signs of RLS:
n Legs feel jumpy and uncomfortable at rest at night
n Compelling urge to move legs at rest at night
n Kick sheets around
n Partner noticing restlessness.
Restless legs syndrome is often associated with deficiencies of iron, folate, B12 and magnesium. Glycine, an amino acid, acts as an inhibitory neurotransmitter in the central nervous system, which relaxes muscles and is useful in the treatment of RLS. Some research suggests low dopamine levels may play a role in RLS, in a similar fashion to how dopamine deficiency impairs motor function in Parkinson’s Disease patients.
RLS can be treated effectively by correcting associated nutrient deficiencies, using glycine supplements and/or medications/supplements which raise dopamine levels. A mild association between xanthine derivatives (coffee, tea, cola, cocoa) and RLS has also been reported in some studies.
Circadian rhythm disorders. Circadian rhythm disorders are a group of conditions in which a person’s circadian rhythm (“body clock”) is out of sync with that of his/her environment. This can have a major impact on sleep. The most well known causes of circadian rhythm disorders are jet lag and night shift work. However, circadian rhythm abnormalities often arise for no identifiable reason, and are present in the majority of people with CFS.
Several treatments are available to correct circadian rhythm imbalances. “Bright light therapy,” administered via a bright light [or phototherapy device] is one primary treatment. Establishing daily routines in regards to sleep timing, meals, exercise and other factors are essential to establishing a balanced circadian rhythm. Melatonin, adenosine and other supplements are useful in some cases. Dietary changes as described in the diet section below are also of value.
Other causes of insomnia
n Medication/drug side effects or withdrawal
n Nutrient imbalances
n Low blood sugar (hypoglycemia)
n Disturbance of intestinal micro-flora
n Toxic chemicals (e.g. lead, mercury) and mold
n Electromagnetic field exposure
n Restless partner
n Waking up to go to the toilet
n Noise (traffic, partner,
n Neighbors, children, weather, etc.)
n Temperature regulation problems
n Night sweats
n Liver function impairment
n Food allergies
n Lung function impairment
2. Temperature Reduction and Optimization
A slight lowering of body temperature which occurs at night plays a very important role in modulating the chemical signals which induce sleep. In one study a group of insomniacs were instructed to have a hot shower approximately three hours before bed. Many reported this had a dramatic effect on improving their sleep.
While you’re trying to fall asleep in bed, always take steps to achieve a comfortable temperature - as being too hot or too cold can inhibit sleep. This can be difficult for people with CFS, as they typically have major problems in thermoregulation [body temperature regulation]. If you are bothered by cold feet in the night, or wake up in the night feeling cold, wear socks to bed. The average optimum room temperature for quality sleep is 19 degrees C [66 degrees F], although this may vary from person to person.
3. Bright Light Therapy and Night Time Light Minimization
When we wake up in the morning light hits our eyes and sends a signal to the pineal gland in our brain, which is a major regulator of sleep in the body. This signal regulates our circadian rhythm (“body clock”). This process can be utilized to improve sleep and is especially useful in individuals with abnormal circadian rhythms.
Hire or buy a bright light [phototherapy device...If you use a box] sit in front of it, looking directly into it at times, for 30 minutes first thing each morning. This must be done at the exact same time every morning; for example, 7:30 a.m. Your face must be within one meter of the light. The brightness of the light is high, usually 10,000 lux [by comparison, the electric light in most homes and offices is seldom brighter than 500 lux]. If you don’t have access to a bright light [device] try sitting in the sun each morning.
At the same time try avoiding bright light for about 1 hour before going to bed and avoid as much light exposure (use an eye mask if necessary) as possible while in bed. Minimize light exposure when getting up in the night (for example, to go to the toilet). Light inhibits the release of melatonin. Some people may be photosensitive. Try avoiding computers/TV’s for two hours before going to bed and see if this helps.
4. Basic Sleep Hygiene
These steps are basic “sleep hygiene” recommendations. They are rarely enough alone to cure serious insomnia, but should be followed as part of a basic foundation of sleep guidelines.
n Have consistently regular sleeping times (such as 10:00 p.m. to 7:00 a.m.). The most restorative sleep, including highest human growth hormone production, is between 9:00 p.m. and 2:00 a.m.
n If too much noise or quiet is a problem in your bedroom try leaving a fan on, use a white noise generator, or wear ear plugs.
n If possible avoid regularly over-sleeping and do not spend an excess amount of total time in bed.
n If your mattress, pillow, or items of clothing that you wear to bed are not comfortable, replace them.
n Do not do anything too stimulating before going to bed (such as Action/Horror/Suspense films or books).
n Try reading a book/magazine while lying down in bed until you have trouble staying awake.
n Do not “clock watch” while trying to get to sleep. Remove your clock from view.
n If possible avoid/minimize napping during the day (particularly after 2:00 p.m.) and if you do nap, do so for less than 1 hour.
n If possible mainly use your bedroom for sleep (rather than for TV, computer use, study, etc.).
n Do not smoke for 2 hours before going to bed, and ideally quit altogether.
n If you do any daily exercise, do this at roughly the same time each day and not in the 3 hours before going to bed. Exercise sometimes has the paradoxical effect of impairing sleep in people with CFS.
n Breath deeply, diaphragmatically, while in bed. Shallow breathing causes metabolic acidosis which impairs sleep.
n Breathing through your nose, rather than through your mouth, improves respiratory function and hormone balance contributing to more refreshing sleep, including higher human growth hormone production. As discussed above, the “Myofacial Toner” [exercise device] strengthens the orbicular muscle of mouth, allowing nose breathing to be easy and natural.
Night time meal size and composition. There is often a connection between the composition and size of your daily meals, and your sleep. Everyone responds differently to different meals, with some people reporting a high whole grain meal helps them fall asleep, while others report a high protein and/or high fat meals helps them sleep. Try experimenting with the following:
Dr. Sidney Baker, author of “The Circadian Prescription,” cites evidence that specific timing of carbohydrate and protein consumption optimizes our circadian rhythm and improves sleep initiation and quality. His basic dietary suggestions include:
1. "Put protein in your morning meal, snacks, and lunch. Emphasize fish, eggs, milk products (for those who can handle them), nuts, peanuts, soy, poultry, beans, and meat."
2. "Move most of your carbohydrates from breakfast, lunch, and morning snacks to the evening. After 4:00 p.m., your goal is to cut back on protein and emphasize healthy carbohydrate-rich foods like pasta, potato, sweet potato and other starchy vegetables, whole grain cereals, seeds, sprouts, and fruit."
Try Dr. Baker’s dietary recommendations for a few weeks, and observe if any changes occur in your sleep or other aspects of your health. Dr. Baker often recommends using 30 grams of protein powder at breakfast meals to increase morning protein intake.
Another time, try making the last meal you have before bed high in protein and low in carbohydrates for a few weeks. For example a non-starchy vegetable and meat/fish dish. Also compare the effect of large meals and small meals as your final meal for the day. You may notice a connection between different meals and your sleep.
General diet recommendations. The following are general dietary recommendations that everyone trying to improve their sleep should follow:
n Avoid caffeine (including in some medications), other stimulants, soft drinks and alcohol after 12:00 p.m. Caffeine’s stimulant effects can last up to 20 hours in some cases. Caffeine sensitivity varies and sensitive individuals should consider avoiding all caffeine.
n Try a strong cup of relaxing chamomile and/or lemon balm tea two hours before bed. Brew with lid on for 15 minutes before drinking.
n Avoid tyramine containing foods (bananas, avocado, cheese, sour cream, pizza, fermented dairy products, beer, wine, MSG, fermented soy products, pickled salamis, liver, caviar, beans) after 5:00 p.m., as tyramine alters brain neurotransmitter levels, inhibiting sleep.
n Avoid “excitotoxin” rich foods: MSG (monosodium glutamate), glutamic acid, or anything that contains the word glutamic or glutamate, aspartame (NutrasweetR), hydrolyzed vegetable protein, red/yellow food dyes.
n Adopt regular meal times, which helps to establish circadian rhythm.
n Balance blood sugar (avoid refined grains/sugar) as hypoglycemia can cause insomnia.
n Don’t drink any fluids within 1.5 to 2 hours before going to bed to minimize night urination.
n Avoid excessively low calorie diets as they can interfere with sleep patterns.
n Spices consumed in evening meals appear to be disruptive to some people, including exacerbating night time heat intolerance problems which can further disrupt sleep.
6. Meditation/Hypnosis/Relaxation Exercises
Meditation and various relaxation techniques can help improve sleep. One basic relaxation exercise simply involves concentrating on individual muscle groups one at a time (for example, feet > calves > knees > thighs, etc.), letting all tension fade away and inducing a feeling of tingling, numbness, and relaxation. Doing this over your whole body is a very pleasant experience.
Relaxing meditation or hypnosis audio tracks work very effectively for some people. They have the advantage of allowing you to sit back, listen, and be guided by the track. Listen to them while lying in bed trying to go to sleep. The following are examples of tracks available online.
n Silva UltraMind Centering Exercise [track - available FREE for download at http://www.silvaultramindsystem.com/products/unlimited/]
n Cure Your Insomnia Instant Hypnosis Track [track - fee-based, downloadable under “health” at http://www.instanthypnotherapy.com ]
n Cure Insomnia Hypnosis Track [ track - fee-based, available as mp-3 download from http://www.sleep-deprivation-cd.com ]
n Sleep Deprivation CD [not a track - fee-based CD from www.sleep-deprivation-cd.com ]
The only disadvantage of audio tracks is that our minds tend to gradually pay less attention to them the more times we listen to them, and we are not developing the skills we do when doing similar exercises ourselves. If you listen to these tracks long term, it may be worth rotating through different ones when they start to lose their effectiveness.
7. Emotional Factors
Anxiety, stress, worry, depression, and compulsive/racing thoughts contribute to sleep impairment, including preventing the initiation of sleep, and impairing sleep quality.
One of my favorite techniques for addressing these issues is taught by Eckhart Toile [author of several books, including The Power of Now ) The situations in our lives are not the sole cause of our stress - the bigger issue is the way our mind interprets these issues and the negative dialogue (such as "I’m never going to get better") it creates. Eckhart Toile’s techniques teach us to take control of our mind rather than being controlled by our mind.
Emotions are influenced by both psycho-social and biochemical influences. A range of nutritional and herbal supplements can be used to modulate the biochemicals (such as serotonin and dopamine) which modulate mood.
8. Nutritional/Herbal Supplements
There are many nutritional and herbal supplements that can help people sleep better. Unfortunately no one supplement helps everyone. Among the most effective in my opinion include the following:
n 5-hydroxy tryptophan (5-HTP) or L-tryptophan.
n Magnesium (chelated, glycinate, chloride, aspartate & orotate)
n St. John’s wort
n Valerian root & hops
I have encountered many people who have gone to health food stores, asked for melatonin supplements, and received homeopathic melatonin. Homeopathic melatonin is not the same thing as regular melatonin and should not be used in its place. Melatonin levels can be measured via a saliva test. Some people find liquid or powdered magnesium to be better absorbed and more effective.
A wide range of nutrient deficiencies can cause insomnia (B1, B5, B6, magnesium, iron & calcium). Supplements should be individualized and guided by a knowledgeable professional and should typically be taken 30 to 60 minutes before bed. A certain amount of trial and error is often required to determine which supplements are most beneficial to you.
Avoid any potentially stimulating supplements/herbs (including many B-vitamins, fish oil, tyrosine, phenylalanine, glutamine, ginseng, DHEA, licorice, etc.) in the afternoon or evening. As a general rule take the bulk or all of your supplements and medications with breakfast. Also ask yourself if any medications you are taking could be affecting your sleep. If any medications or supplements you are taking are impairing your sleep, ask your health provider for possible alternatives.
9. Electromagnetic Field Avoidance
Electromagnetic fields (EMFs) lower levels of melatonin and impair our circadian rhythm. Some people appear to be more sensitive to the effects of EMFs than others. Consider sources near your bed: power boxes [other side of wall], clock radios, mobile phones, phone charger, cordless phones (especially DECT cordless phones), electric blankets, coils of cable, waterbed heater, computers.
Keep electrical devices in your bedroom as far away from you as possible and ideally unplugged. Avoid other major sources in the hours before going to bed: operating microwave ovens, operating electric toothbrushes, etc. You may even wish to turn the power off at the mains for a night and see if this makes a difference. Some people may wish to consider renting an EMR (electromagnetic radiation) meter.
10. Chemical Avoidance
Some individuals are also sensitive to environmental chemicals, molds, and dust mites, which can impair sleep in some cases. Keep your bedroom very clean from dirt, dust, mold, etc. Follow the guidelines below to minimize environmental chemical exposures in your bedroom:
n Never smoke or allow anyone to smoke in your house.
n Ensure good ventilation in your bedroom. Keep windows open as much as possible.
n Don’t spray insecticides or other chemical sprays inside or outside your home.
n Avoid all the following products in your bedroom, as they pollute the air you breath: mothballs, hair sprays, air fresheners, stain removers, dryer sheets, essential oils, aftershaves, fabric softeners, deodorizing products, scented products, nail polish remover, nail polish, glues, paints (use water-based and the least odorous paints and adhesives), smelly plastics, plastics generally (including furniture), waxes or finishes, degreasers, spot removers, urethanes (such as hardwood floor covering), varnish, flea sprays for pets, pest strips, DVD/CD cleaner spray. If you have to use these products use them in another room, or ideally, outside.
n Use 100 percent cotton sheets and pillow cases. These should be washed regularly using a synthetic-chemical-free washing powder. Replace your pillow with a 100 percent cotton pillow. Pillows accumulate large quantities of dust mites and mold spores.
n Hang newly dry-cleaned clothes outside until they lose that chemical smell, and don’t store in your bedroom.
n Keep computers, faxes, and printers out of your bedroom as they release volatile organic compounds (VOC’s).
11. Experimental Therapies to Consider
n Emotional Freedom Techniques (EFT). [www.emofree.com/] Anecdotally appears to help some people with insomnia.
n Subliminal messaging [www.drbate.com/Auditory.html]. Informal research by Dr. Phil Bate reports that subliminal messaging is effective in treating insomnia.
n Acupressure points [see: www.holistichealthtools.com/insomnia.html] have been studied in the treatment of insomnia.
n Some eastern medicine groups claim that having the head of your bed facing north allows your body to be in better sync with the earth’s electromagnetic fields, allowing you to get a better night’s sleep.
n Try sleeping with a bag of lavender in your pillow. Inhale the lavender smell deeply through your nose.
n Massage. Massage raises endorphin levels.
Note: This information has not been evaluated by the FDA. It is not intended to diagnose, cure, treat, or prevent any illness, disease, or condition. Importantly, you should never make any change in your health care or support plan without reviewing and discussing it in consultation with your professional healthcare team.