What is sleep hygiene? Most of us know we feel better after a good nights sleep, but how can we maximise patient wellbeing through sleep?
Today we are joined by naturopath and sleep expert, Norelle Hentschel from Your Sleep Remedy to take us through the vital components of attaining restful, rejuvenating sleep for ourselves and our patients. With so much to cover in a single podcast, we've broken it up into a two-part series. In part one, we look at the hormonal and lifestyle drivers of sleep and the many modern-day issues that interrupt our crucial sleep cycles.
Covered in this episode
[00:47] Introducing Norelle Hentschel
[01:41] Norelle's background
[07:35] Introducing the concept of sleep hygiene
[13:36] Screens and artificial light
[18:46] Blue wave light: LED and Fluorescent lighting
[19:47] The hormonal drivers of sleep
[25:52] Sleepiness vs. Tiredness
[28:20] Is the dimming function on screens enough?
[30:06] Music and other sleep resources
[32:20] Do we know the purpose of sleep?
[33:21] Sleep and our metabolism
[37:00] Middle-age sleep disturbances
[42:03] Sleep apnoea
[45:18] Caffeine: not a problem for everyone
[49:00] Alcohol: a double-edged sword
[58:45] Shift workers
[1:03:30] Approaching interventions
[1:06:35] Plans for podcast part 2
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining me on the line today is Norelle Hentschel. She holds a Bachelor of Health Science in naturopathy and has a private practice called Your Remedy based in Crows Nest, New South Wales. Norelle graduated as dux of her year in 2015 with a Bachelor of Health Science in naturopathy.
Since then, she's been in clinical practice in Crows Nest, with a special focus on helping people get better sleep. She's passionate about patient education and health awareness and focuses her treatments on diet and lifestyle modifications so that her patients attain their best possible level of wellness and vitality. Norelle has a special interest of sustained food as medicine, digestive health issues, and natural approaches to menopause. Welcome to FX Medicine, Norelle, how are you?
Norelle: I'm very well. Thanks for having me on, Andrew.
Andrew: Now, I first think we need to go into your background because you've got a very interesting background from not just a totally different profession, but also your history when you were a child. You're 4th generation farming stock?
Norelle: That's correct. So I guess my story and my journey into being a naturopath has kind of almost come a full circle. I grew up on a dairy farm so we were, you know, we grew our own vegetables. We obviously had plenty of milk. And takeaway food was not an option for us because we lived out of town.
Norelle: So everything was, you know, home-cooked. So all in all it was a nice healthy lifestyle. As I was growing up, I was quite keen to be a doctor or a vet. But I was really very shy as a child. So in high school, I thought I'd take a drama class to try and overcome the shyness.
Norelle: Yeah, and as a result of doing that I kind of got a bit seduced by the bright stage lights, as they say. And I went off to the big smoke in Brisbane to study a Bachelor of Arts in drama.
Andrew: Wow. So I've got to say, I mean, that's actually strength in itself. So this is something that really amazes me about quiet achievers, about these quiet, supposedly shy, people. They're actually quite strong. Whereas me a s a peacock I'm just a wuss. So that's actually a very strong thing to say you chose yourself to face your own fears.
Norelle: Yeah, and for me, it was really quite tough because I was, yeah, really on the introverted scale. But I think I knew even, like, when I was at high school that I needed to overcome that otherwise it was probably going to be something that would hold me back. Because underneath it, I'm probably quite a determined focused personality, as well.
So yes, it was...probably looking back it was a bit of an interesting decision for a teenager to sort of make/ But yeah, it certainly led to some adventures after that. That's for sure. I got to travel overseas. I worked with the Swedish magician for a couple of years touring around Europe. So that was you know, for someone in their 20's, that was a lot of fun. But it wasn't perhaps the healthiest of lifestyles, lots of roadhouse style food.
Andrew: I would imagine.
Norelle: As you would imagine, the menus aren't on the healthy range of the scale when it comes to that. And it also actually worked against my natural morning-person tendencies. Being from a dairy farm. That was bred in my DNA. And yeah, my sleep did start to decline during that time. So yeah, the lifestyle wasn't exactly the best one for me.
And then a couple of things kind of happened to really make me question my career choice. And that was the first one was my mother developed colon cancer.
Norelle: Now, happily, she's been eight years in remission. So that's great and the second one was that my brother suicided. So his death really escalated that insomnia. And it became a chronic kind of thing. And at one point, I was only sleeping three or four hours a night. So I became quite anxious, I gained weight, I had...was irritable and not, you know, I wasn't in a good place in terms of my health and that. And, you know, compared to sort of where I come from growing up it was a big disconnect. So I kind of knew that I had to make a change in my life and go and do something else. And so I rediscovered natural medicine and I got interested in naturopathy and decided to study it. And now, here I am.
Andrew: Get back to where you once belong, as the famous song said.
Norelle: Yes, indeed.
Andrew: So was there a true acceptance in your family of natural medicines or was it something that you came back to try and find an answer for things?
Norelle: I think there’d always being in my family...there’d always been a focus on, not overtly, on natural medicines, but certainly to not necessarily run off to the doctor every time there was something, you know, wrong. There was more a sense of, "Let's try and fix this ourselves. Let's have a good diet. Let's have chicken soup. Let's have you know, hot lemon and honey drinks," when you were sick, all that kind of sort of approach to things.
So I'd say overall, probably my family has a balanced view of health. You know, they're not one way anti-medical establishment by any means. But they're not sort of, you know... They're looking to support a healthy lifestyle would be the kind of the way that I grew up.
Andrew: I think we, as a society, could learn so much from that approach. That look, "Let's toughen up for a second and let's just handle this and see how far we get."
Norelle: Yes, indeed.
Andrew: Because, I mean, doctors themselves will decry just how many useless times, useless visitations, they get from patients seeking treatments that they can't...that they have nothing to offer for. And I just wonder whether we, as a society, are falling into this ‘everything needs a pill,’ you know?
Norelle: Yeah, well, definitely. And we've sort of have forgotten some of those more basic lifestyle kinds of interventions. And, you know, profit was the practical thing. It's, well it's just not so easy to run off to the doctor when, you know, you're out in the country. It’s a, you know, it can be a bit of a trip and a trek and take you away from other things that you need to be doing. So there was I suppose that aspect of it, as well too.
Andrew: Talking about sleep hygiene, did you find that just going back to your roots, if I can use that term, did you find that just learning the natural therapies there are available actually helped your sleeping in part. Or did you have to actively search for these sleep hygiene measures?
Norelle: I think when I looked, when I was going through it, there is a lot of general information out there on sleep hygiene. But it's the application of it into a specific case that's sort of lacking. Because, like, there's probably about 15 different core recommendations for sleep hygiene. But not all of them are going to apply to each individual.
And it's quite interesting because the guy that's credited with, you know, having sleep hygiene, Peter Hauri, a psychologist in the 70's, kind of came up with the term. And it was about having these daily habits that would help you get quality nighttime sleep and make sure you are fully alert during the day.
And his whole thing was that he said, "You really have to customise it to the patient that you should give them two or three key recommendations of those sleep hygiene things that they can implement." Otherwise, it becomes just a broad base thing that people don't really know how to implement.
Norelle: Which I think is kind of interesting from a naturopathic perspective because that's how we're treating people anyway, you know, very much a customised solution. Yeah, so it was quite interesting when I did research and found that out, you know, after I become a naturopath. It was like, "Oh, that's might be why some of these generic things didn't work for me at that point in time."
Andrew: I think what's interesting is the even the definition of hygiene. Most of us would now think of that word as being clean or sterile or sanitised or something like that. And particularly with the preponderance of the "Dettol generation" type ads of cleaning, you know, every surface that you can think of with benzalkonium-type cleaning fluids and getting rid of every source of natural bacteria that inhabits the world. But, indeed, the word hygiene is from the ancient Greek meaning the art of health.
Norelle: Yes. So it makes sense why he probably chose that. But I suppose yeah, as you say, the context that we look at the word hygiene now probably makes it a little bit more difficult for the lay person especially to understand perhaps what those principles are really getting at. And a lot of them are quite common sense you know, you could say, if we can still use the term common sense these days.
Andrew: Does it exist?
Norelle: Indeed. So, I mean, the basic ones of, you know, caffeine. You know, most people know that you know, if you have a large coffee before you go to bed, sleeping will probably be a little bit difficult. I think that's quite well-known.
But there's some other ones that, you know, are a little bit less well-known or have been harder to implement. So those are ones that are often interesting to introduce to clients and they can get to then think about their sleeping in different ways. One that I'm using quite a bit in the clinic at the moment is; it wasn't on his original list, but he did introduce it later in his time. And it’s about stress, which you know, we all know about, especially as naturopaths. And he called the thing this anticipatory stress.
Norelle: So often at night time, he said that a lot of people the first time they kind of get to kind of unwind from their day is when they jump into bed. And so suddenly, all the things that they haven't sort of had time to sort of think about come up in their minds. And so their minds start ticking over and becoming really alert.
So he was advocating that you have a wind-down time where you either...you know, journaling is quite popular at the moment and can be very effective for a lot of people.
Norelle: Writing a simple to-do list, you know, that's a basic kind of thing to kind of get it out of your head and so you don't have to think about it as soon as you jump into bed. So yeah, and meditation is another thing that is quite beneficial for a lot of people to do either, you know, before they go to bed or as some part of their day to actually get that, you know, relaxation mode.
Norelle: Rather than being in that you know, more fight-or-flight sympathetic dominant mode.
Andrew: You know, that's something I've never even thought separately about was that anticipatory stress thing. About it's the first time that people get to actually wind down is once they're in bed. That's A) sad, but B) very interesting that we need to actually separate the place of sleep from a place of relaxation or wind down. Is that how you teach people to do it or can they do it in bed?
Norelle: Oh, I prefer them, like you say, to separate the sleep environment from their work environment or, you know, whatever else is going on. So I think it's beneficial to do it prior to getting into bed so that when you're getting to bed you really your head space is quite, you know, clear and ready to go to bed. If it doesn't suit, you know, people say, "Oh, I can't do it," I'd say, "Well, you know, have a routine when you do get into bed." But ideally, you want to associate going into bed with being already relaxed.
So yeah, it is something that I really do focus on more and more because I find a lot of my sleep clients, it is this stress component that they haven't dealt with their day time stuff. They haven't released to let them get into a relax mode to going to sleep mode.
Andrew: Ordinarily I'd think of asking this question a little bit later on in the podcast, but I think now is the appropriate time. Teenagers, you're talking about bedrooms and the bed being the place of sleep trying to tease it apart from a place where you wind down.
But teenagers, you know, traditionally stay in their room, grunt from the inside about when they want food. And they very often hibernate in their room where they are actually stimulated. Being on the computer, their devices, that sort of thing, not the least of which is in bed. But even as part of the bedroom, they don't have a separate place where they can say, "That place is now ending where now is my place to wind down."
Is this one of the reasons perhaps that we have such an issue with teenagers? I know that doesn't answer pre-iPod, pre-tablet type society when, you know, teenagers we're still nocturnal. But, you know, they've sort of hibernated in this room. They don't have a disconnect.
Norelle: Yeah, and that is actually a fair point. Because it is, you know, so often you have to have your study desk. I know as a teenager... and that was pre-internet, pre-iPad. And that's really dating me now.
But you do have all that stuff in your room. And then, you know, you're keeping all these things in your room because that's your space. So you've potentially got a lot of distractions in there. So I do think it is a challenge for that. But on the upside, it's normally a time in your life where you don't have these other things that can interfere with sleep like say, you know, hopefully, you don't have any other co-morbid, you know, conditions that would interfere with sleep.
So a bit of sleep hygiene can actually really be helpful. And a lot of it is actually about these days I find is the devices themselves. To kind of be able to kind of pullback that stranglehold that these screens, which so addictive, have.
And there was a very interesting meta-analysis in The Journal of The American Association last year. And it said that in the U.S., there was almost 90% of teenagers had a device, at least one device, in their sleeping environment.
Norelle: And that they were using it and displacing their sleep and they did...the conclusion was that it was actually, you know, a reasonable public health concern.
Norelle: For this. So I would agree. I think that's one of the things it certainly changed over the last 10 or 15 years, the amount of screens we have. And, you know, the teenage generation now, that generation has sort of grown up with that.
So, like my, generation I didn't have that. So for me, it's probably not as addictive to want to have that. But if you don't know any different, it’s, I think it's...yeah, it's harder to break that addiction to not be on your phone in bed and, you know, reading on an iPad rather than a book. And its used at schools and universities and all that. So, you know, it's part of so much another extension of their body, these devices.
Andrew: So I have to ask now then, you know, iPad, tablet, phone, bright screens, have really only been with us the last, I mean, less than a decade really.
Obviously, people suffered from insomnia prior to that. And obviously, sleep hygiene has been around, the methods of sleep hygiene have been around for some time before that. So what were the causes back then? Was it only stress?
Norelle: No, I think there's probably a, you know, a few different things. There's probably exercise is a big one that can, you know, make a big difference in terms of being able to sleep better. If you're not getting sufficient amounts of exercise or doing it at the right time. So people who exercise too vigorously too close to sleep can have...
Andrew: Yeah, they're still wide awake.
Norelle: Issues with yeah, going to sleep. But also that the fact that the're maybe not doing enough exercise. There's good research for older people with sleeping problems that if they, you know, increase their exercise to 30 to 60 minutes a day, within a month their, you know, total sleep time will increase quite a bit. And they'll have deeper sleep.
So and I think there's always been things with circadian rhythm dysregulation, people not exposing themselves to light and that. So you've got light from the screen but also, you know, oftentimes we end up spending a lot of time indoors. When we may be transitioned into more people working in offices, office environments, you know, less manual work, outdoor work. And because that's the case, you know, the sun sets. And the daylight sets our rhythm and synchronise our clocks and help us you know, have the good flow of our cortisol and melatonin and that, as well.
The other thing that I think in terms of light, which is there's no research to back this up solidly. But I think fluorescent lighting and LED lighting also plays a part in that, as well, in terms of our internal light.
Norelle: And that's the style of the light bulb that emits this kind of blue wave light and interferes with our melatonin production.
Andrew: Ahh, now, that's something I want to delve into. So it's blue light? Because there’s proponents of blue light, isn't there?
Norelle: Well, you can use it, if you've got certain sleep disorders to move circadian... like, you phase shift people with that.
Andrew: Yeah, yeah.
Norelle: But generally, blue wave light's on the short wave of the light spectrum. So it will suppress melatonin production.
Norelle: That particular light. And there is evidence that a warm kind of tungsten, what they call a tungsten yellow, reddy kind of...not, you know, infrared, but in those tones doesn't interfere as much with your melatonin production.
Andrew: Ahh, so I think...well, I think we need to delve into this. The controllers of sleep. The hormones that we get released in a time-wise fashion. And what interests me is the flipping sort of effect that we would think serotonin, for instance, would have, you know, normally, we would say it's a stimulatory or a darkness hormone or neurotransmitter.
Andrew: But it has different effects when we're preparing for sleep. Is that right?
Norelle: It does. And you need to have sufficient amounts of it. Well, firstly serotonin is the precursor to your melatonin.
Norelle: It converts along with SAMe and Vitamin B12 into melatonin. Things that can kind of impact your serotonin, of course, are if your tryptophan is getting shunted down a pathway to make B3. And that can be because if you're consuming a lot of alcohol or if you've got dysbiosis.
So you can actually have a shortage of, you know, the building blocks, the amino acid building block, to kind of kick it off. And that's not uncommon, you know? Especially with increasing amounts of digestive diseases, that when you sort of trace people sleep problems back you sort of go, "Ooh, I think this could be a bit of a driver, that their melatonin, they're not actually making enough melatonin." And then, you know, we can sabotage your melatonin on all these other ways by light and stress and you know, insufficient amounts of magnesium, which is depleted with stress. So it kind of becomes a little bit of a vicious cycle.
The two key hormones I suppose that really drive the circadian cycle your melatonin and your cortisol. So cortisol is what I tell people in clinic, "It's your get up and go hormone." It rises in the morning and there's a little bit of a dip in it in the, you know, the early afternoon, early-to-mid-afternoon, when we kinda get that 3:00 am slump. And then it will pick up again. And it will… depending on what your chronotype is naturally, between 7:00pm and 1:00am you'll get a drop. And that's what they call your peak alertness period.
So ideally, you want to be trying to go to sleep after that peak alertness period in the evening. So, like, I know mine, for example, is around 9:00 in the evening. So if I tried to go to bed before 9:00, I would probably have difficulty going to sleep. Because my body in the circadian cycle is not ready for that. Whereas I definitely know my father who is around 7pm because he's a was falling asleep in front of the news, the 7:00 news. So, like, his is a little bit earlier.
Andrew: But is that a natural state or is that a state brought on by stress or necessity or...
Norelle: It can be a normal state for someone who's probably... And you know, he's probably someone who is a extreme lark, what they call an extreme lark chronotype. So really, an early morning person and you know, given that he would be up at 3.30 am you know, when he was on the dairy farm. He's retired now. But I think old habits die hard. And so that's his sort of natural thing. Whereas some people are naturally more, you know, the night owls.
Andrew: Yeah, okay.
Norelle: They don't go to bed until much later and that is their natural state of being. And there's some evidence that there's actually genetic, you know, ways that that is determined by your genetics.
Norelle: Like, if your family tends to be more to morning people, you will probably be that way…
Norelle: ..Than more evening, kind of. And then there's people who sit in the middle. And, you know, modern lifestyle is kind of designs for the people that sit in the middle. I think The Sleep Doctor, Dr Michael Breus, calls them bears.
Norelle: Yeah. He's got four chronotypes in his situation.
Norelle: So, yeah, so there is that sort of...you know, within your circadian rhythm there is that drop in alertness that you have in the evening, whenever that falls for you. And then the other thing that plays into sleep is your sleep homeostatic drive.
So that happens as a result of the accumulation of a chemical called adenosine, which is produced by your brain when you're awake. And ideally, that is building, building, building during the day. So that by the end of the day, your what I call your sleep pressure is quite high so your sleepiness. Not tiredness. They're sort of two different things. You can be tied without being sleepy. And you want to…Your sleeping sweet spot is kind of when that deepening alertness falls for you and when you've got your peak kind of adenosine happening and you would really fall to sleep very easily at that point in time.
So that's kind of the ideal spot to go to bed. And I...in clinic sometimes I'll get people to track their peaks of alertness, like, throughout the day. How alert they're feeling. So you can...they can kinda find their own individual one. And then they can use that information to look at , "Okay when is the best time for me to go to sleep?”
Because there's another key thing that is in the sleep hygiene research is that going to bed before you're sleepy is really counterproductive.
Norelle: Because it creates stress in and amongst itself. So you actually want to make sure you're sleepy before you go to bed. And if you're not really sleepy when you go to bed, you're better off getting up for a bit and doing something calming and relaxing, not on your iPad.
Norelle: As one of client's said, "Yeah, I'm getting up and reading," I said, "Oh, what are you reading?" "Oh, I'm reading on my iPad," and I'm like, "Oh, okay, I see the problem here."
Norelle: You've always got to remember to keep asking the questions down the line and don't just assume. Not just assume.
Andrew: Yes, I remember those things called books. Yeah, I remember particularly when they used to fall on my face. Donk.
Norelle: Yeah, exactly.
Norelle: Well, it can be a little bit tricky, especially in these clients that have had this condition for a while and they may have a chronic fatigue picture. And then they have adrenal kind of stuff going on for them.
I sort of like to kind of describe it a little bit as sleepy is when you've got that litter that book falling on your face or you're in front of the TV and you're going off to sleep. Whereas tired is just that feeling of, "I've got no energy. I'm exhausted, but I'm not ready to go to sleep." And most people when they start actually tuning into that a bit more can kinda go, "Yeah, I am feeling tired. But there's no way I could go to sleep at the moment."
So yeah, it is one of those ones that, you know, is sometimes a bit of a more of a challenge to get people to tune in and listen to that to go, "Okay, what's the difference between being tired and what's the difference between being actually sleepy?"
Andrew: And I actually wonder whether when you're tired, but not necessarily sleepy, and you try to go to bed... I think you mentioned it before, that you might have this sort of flight-or-fight response that might happen? If there's some underlying stressor that you haven't addressed. And then you actually end up up waking up. Do you ever...
Norelle: Yeah. And that's that classic picture of these people who will go to sleep... They will be so worn out that they go to sleep. And they'll sleep for an hour or a couple of hours. And then they'll wake up and they will feel really alert.
Andrew: So is that the anticipatory stress or is that something different?
Norelle: Well, it can be a couple of things. It can be, you know, their blood sugar might not be as well regulated as they like. If their adrenal function, you know, can't sustain kind of an overnight fast. And the body will push out some adrenaline and wake them up.
Norelle: It can also be because their melatonin will rise to a little bit. But the cortisol hasn't dropped enough. And the melatonin kind of can't sustain enough to, you know, keep them asleep. And that… magnesium can be really useful for people who kind of have that. Because magnesium helps your melatonin hang around and stay around for a lot longer. And also it calms the nervous system down and relaxes generally.
Andrew: So we've spoken a few times about these bright screens. I've noticed on my iPhone... Indeed, I employ it. But after a certain time at night, you can have that dimming effect. Is that useful or is it really a sham?
Norelle: It is useful. It's partially useful. I'll kind of give one of those answers.
Norelle: I think it helps with the blue light situation. So that’s stopping the melatonin, helping the melatonin, not to... but I kind of say, "Look, it's a bit of a crude fix." The other thing that happens with screens and that is that they stimulate, just by the content that's on them.
Norelle: So you're stimulating you brain with oh you know, yeah checking your social media and seeing, "Oh, my God, what's happening there? And, you know, this has happened in the world." And so your brain starts thinking about those things. Whereas if you were, you know, say reading a book, you wouldn't necessarily have all that sort of... And changing stimulation is the other thing that screens give you. Because, you know, we often flick between multiple different things, as well.
So I think while new things like what they have in the iOS now to do that. And there's also a program that you can install called f.lux, which is quite good. It takes the blue light out of your computer screen so you have it. And that can be quite useful for people studying who need to sort of, you know, study at night. And I know when I was studying, I used that program. Because, you know, sometimes that's the only time you've got to, you know, do your study, so you do need to do that.
But yeah, there's the other component of the screens is actually the stimulating content component that doesn't do much for your sleep.
Andrew: What about the facility of various types of music to enable, to induce sleep? So things like you know, Pachelbel's Canon in G, for instance, is famous for inducing Alpha because it works on that, forgive me, if this is wrong. It's 8 to 14 cycle per second. It's sort of known for inducing Alpha waves.
Andrew: There's various other types of classical music. I mean, one of my favorite things is Holst, "The Planets."
Norelle: Yes, yep.
Andrew: Yeah. And, you know, there's various multiple new-age type music, anything from Tony O'Connell through to Andreas Vollenweider, you know? So there's all of these different types of music. Are there any specific types that are better or worse for sleep?
Norelle: I think generally when people say to me about music for sleep, again, it's sort of, you know, on that stimulation scale. If it's something that you kind of would want to get up and dance to, it's probably not ideal for, you know, your sleep.
Andrew: Or head bang to.
Norelle: Head bang to or is going to annoy your mum or something like that, it's probably not going to be. So you do want that. you know? And there's...a lot of classical music is, you know? Well, not all classical music. But there's a lot of classical music that can be quite, you know, beneficial in that. And there's a lot of very... If you go on to, you know, iTunes or Spotify, there's whole playlists and albums with specific sleep-inducing... and look. I've got and I use some that are recommend in clinic to people. And, you know, I find myself sometimes, if I'm having problems winding down, they can be really useful just having the background as you, you know, drift off to sleep, as well. So I think there's yeah, definitely something for that, you know, the whole Brahm's lullabies.
Norelle: That they have for babies.
Andrew: Would you have any resources that we can put up on the FX Medicine website for our listeners to access?
Norelle: Yeah, I do have some stuff that I recommend routinely in clinic. But they're not my specific resources. But they’re ones that other people have produced.
Norelle: And yeah I recommend them, so I'll send them through.
Norelle: Yes, that's… I don't think there's any definitive stuff. And there's been...there's a lot of research being done to try and find out about it. We've definitely moved on from the ‘sleep is just when the brain shuts itself down and nothing much is happening.’
Andrew: Well, it doesn't.
Norelle: Yeah. No, we're actually...the brain is actually really quite active, but in a different way and in different wavelengths. And normally but yes, there are a lot of things that are happening when asleep. Some of them are, that we do know about, is that learning and memory is really impacted on sleep. You help consolidate your memory. So short-term memories go into long-term memories. So students, the best thing you can do before an exam is actually sleep, not stay up all night and cram, if you want to remember stuff the next day.
It's an area that I'm really interested in is how it impacts on metabolism and weight gain and the interplay of the hormones and that, that lack of sleep influences. So if you don't get enough sleep, your satiety hormone, leptin, decreases the effect of that. And the appetite, you know, ‘I'm hungry hormone,’ ghrelin, rises. So you get these subjective feelings of hunger, let's say. Which is thought to be because your body thinks it's got to stay awake for longer, so it's going to need more energy. The brain doesn't want to run out of energy, so you get those signals that you've got to eat.
And some research tends to decide that you want that calorie-dense carb food.
Norelle: Is what you really start to crave. And most people would know, if they've had a night where they haven't slept so well, yeah, you do tend to be wanting to reach for the muffins and, you know, the donuts kind of end of the food spectrum, rather than you know, fruits and healthy foods.
Andrew: I even remember some practitioner recommending that people have a high carb loaded, smaller meal towards sleep. And I thought, "What? That's a bit of a bandaid isn’t it?" I couldn't ratify it. But what I guess what I'm interested in, what about the midnight snacker? What about the person who goes to sleep and then wakes up?
Norelle: Yes, and that's an interesting one. And I think I have looked at that question because I've kind of wanted to determine.. because you hear people say, "No carbs at night. You know, that's bad. You won't sleep or you have lots of protein at night." And again, I suspect there's probably a bit of individual variability, you know, to that. Like most things, there's no one, you know, answer that answers it for everyone.
Norelle: But I think the people with the carbohydrates craving I suspect there's probably a little bit of blood sugar dysregulation…
Norelle: Going on there where it isn’t overt that you would see that in a blood test or if it's a, you know, pre-diabetic kind of state where they are not able to, as I was talking about before, maintain the overnight fast. Their adrenals aren't able to release enough glucose. And the brain kind of, you know, wakes them up to say, "We're hungry feed us some stuff."
But I've also seen people who do really well with a little bit of a protein snack before bed. So yeah, I think it can go either way in terms of that. And it does always make me want to dig further into how their blood sugar and their adrenal function is when people tell me, "Oh, yeah. I get up in the middle of the night and have some toast."
Because I think it's Henry Osiecki talks about in his sleep stuff where you actually do need some energy to sleep. And there's some stuff going around I saw on a blog or something the other day where honey and salt...there was some kind of concoction of honey and salt that supposedly cured insomnia, as well. And that's probably working on that, you know, providing some glucose and energy before you go to sleep.
Andrew: Right. Okay, honey and salt? That's an interesting one.
Norelle: Yeah, so I was wondering if that salt was, you know, to keep, you know, adrenal function and yeah. So I haven't found out the reason though.
Andrew: Yeah. What about, you know, the sort of middle age thing? You know, we attribute, let's say women might be more aware of the symptoms of hot flushes and anxiety at night, whichever comes first there.
Andrew: And that might interfere with sleep. But men get these sorts of things too where anger might creep into sleep or interfere with their sleepfulness.
Norelle: Yes, that's true. And I think there's a couple of things going on with, as you get into, you know, your 40's and beyond is one thing is that melatonin production naturally declines a little bit. Also, there can be the effects of a less than healthy lifestyle building up. And traditionally at this point may be, and I think also where we're at is it's a lot of stress just generally in life in sort of your 40's. Like, often people with starting families a bit later might have kids still...they're just going...they're just becoming teenagers.
Andrew: Oh my goodness.
Norelle: And that can be quite stressful for parents. Big mortgages, you know, are quite common where that one time I suppose a lot of people might have owned their own home by the time they were 40. I think these days it's a little bit...that's getting pushed back more and more.
Also, just in terms of the job, a lot of people might have jobs that are at the higher level of responsibility. So there's more work worries associated with that and yeah and sometimes health conditions starting to kind of come in at that point that they haven't been aware of. And, you know, and their parents, as well. When you get into your 40's, your parents are normally getting normally a bit older. So there's also that worry about health of, and looking after your parents and that too that plays into that, as well.
As well as women obviously have hormonal shifts that, you know, the changing of oestrogen and progesterone. So that can impact greatly on sleep. Well, women's sleep can be impacted on...just in the monthly cycle because progesterone tends to make you sleep better. So in the second half of your cycle, just, you know, as a monthly thing. But as I start to go through peri-menopausal things, the oestrogen fluctuations, which start to set off those hot flushes because oestrogen helps and serotonin regulate the thermal regulation. They interplay into that signaling. So if your temperature goes up during the night, you sleep better when your core body temperature is lower. And if your temperature is going up a little bit, it's enough to kind of make your sleep restless and disturbed.
Andrew: I learnt this from Jerome Sarris about that temperature issue, that our temperature naturally...our sort of set point naturally declines, so that we may be a little bit colder or cooler. Let's say the word cooler, during sleep, our body temperature decreases. And that's our basal metabolic rate. You're tied to it.
Andrew: But what I find is interesting and I was talking with Moira Bradfield about this going, "You what?" And she was talking about the people that need to just stick a foot out of the side of the bed. And that's enough for them.
Andrew: It peaks my interest because, like, I cannot sleep when I'm too hot. I just cannot do it whereas my wife would be... You know, she used to lump the blankets on herself. And, of course, she's been through menopause and she's ridden it very well. But even to this day, she needs... I prefer a very cool room and Lea likes to feel really snugly and warm. It’s a real set point difference in our body temperatures.
Norelle: Yeah, and that's not uncommon. I think men and women tend to have different, you know, well different, you know... Well, there's different metabolic rates snd that between men and women naturally.
Also, you know, thyroid stuff comes into it. Women can tend to be more...have issues with thyroid than men.
Norelle: So stuff like that can happen. And, you know, there’s those wonderful doonas that you can get there actually kinda half, you know, a lot lighter weight for the guy and, you know, a heavier weight for the woman.
Andrew: And then you get around the wrong way.
Norelle: And then it all goes, yeah, at some. But melatonin also influences your… that's one of the things that melatonin does is it actually drops that core body temperature. It helps that core body temperature to go. So if there was differences in, you know, melatonin output and timing in that, that could also affect temperature, as well.
But I think though that what they say is they recommend is around 19 degrees in the bedroom is kind of an ideal temperature.
Andrew: Got you.
Norelle: And most people would probably say they sleep better in winter or, you know, the change of seasons rather than those really hot summer nights, yeah.
Andrew: What about the issue of quality versus quantity? How do we know we're getting good restful sleep rather than just a lot of time asleep? And indeed, I've got to ask here, when would you start to suspect a red flag that something might be wrong here, like sleep apnoea?
Norelle: Well, sleep apnoea, I would be suspecting, if they are feeling constantly tired and unrefreshed from their sleep. And in the absence of other things, the other big red flag for sleep apnoea is snoring.
Norelle: If they snore and so that's often, you know, you ask them, if their partner complains about their snoring. Or there's actually apps that you can get that record your… The SnoreLab is one that I get people to use.
Andrew: Ahh, ok.
Norelle: And it will record your sleep over various amounts of nights and give you a ‘snore score.’ And while that's obviously not like being in a sleep lab and having the machines and all that paraphernalia, it does give an indication if it's something that should be further investigated and referred to a GP, who can then refer onto a sleep study to get that apnoea diagnosed.
Another thing would be if they are overweight and suffer from reflux and things like that, I would start to think, "Okay, we're looking potentially at sleep apnoea," and it's quite a common thing to find.
Andrew: Oh, I see.
Norelle: People have that. And obviously it's one that you do want to get addressed.
Norelle: Snoring is not necessarily just an annoying situation. It can actually have health risks. Especially for your cardiovascular and your mental health, like, it can kind of lead to dementias and stuff like that there. Research is pointing to that now, just because of that loss of oxygen to the brain.
Andrew: And I might point out for our listeners that sleep apnoea is not necessarily... Although commonly, it is not necessarily just tied to obese people. Indeed, I had an ex-colleague whose husband died, a fit young healthy guy who died in his sleep. And he died from sleep apnoea. And it was devastating.
Norelle: Yeah, that's very tragic and it's a very good point you make there, Andrew. Yeah, it's not just with people who are overweight or obese. It's, yeah. It can happen to everyone, anyone, you know, who, you know, is having those moments where they're just not breathing, you know, during the night…
Andrew: Yeah. So that’ unrefreshed sleep. Tired during the daytiome. Particularly trying to all or particularly finding they need to nod off at certain periods during the day.
Andrew: That's a red flag and should be addressed.
Norelle: Yes, definitely so it's one that I definitely refer on to and get them you know, sorted out. And, you know, sleep studies these days are a little bit less arduous than they were in the past. There's not so many... People can actually have a reasonable sleep quality when they go in there. There's not so many cords and wires. And they can move around a bit more than they could in the past too.
Andrew: Yeah. What...I got to ask what about these contradictory issues, if you like? We would ordinarily think that caffeine and the stimulant type things can interfere with sleep. What about the people that say, "Ah, I love a cup of coffee before sleep. I love a cup of tea in the evening."
Andrew: What about that like is that something to do with improper detoxification or is that just the way they handle it?
Norelle: Well, I think the studies looking at caffeine, they haven't found strong associations. It's one that they kind of, when they look at sleep hygiene and study it in clinical settings they sort of go, "Oh, we don't know about this." And I suspect it's because of those variabilities in caffeine tolerance and the detoxification pathways of caffeine for certain people.
But yeah, I've got a client that, yeah, literally can have, you know, coffee before bed and claims that it doesn't impact. I'm sort of, you know, "Wow, that's really," because I'm very sensitive to caffeine.
Norelle: So I would never dream of doing that, but yeah. So it's like those people who can take B vitamins at night and not affect them greatly, as well. So you get people that are a lot like that and can do that. But I think with caffeine, it is really, yeah, individual. And it's also how much you actually consume.
Norelle: If you're a high, regular high caffeine user, you going to have a tolerance to it, rather than someone who occasional uses it or only has one coffee a day and then suddenly starts having more.
And they sort of found a lot of that when they do… because athletes use caffeine a lot in their training and for performance. So they've studied athletes. I mean, that's obviously groups that are a little bit different from the rest of us. But they have found that, you know, in terms of...because they want to look at when they can use the caffeine to get the best performance out of them. And it is...they have found that some people can use it quite late in the day and not be affected by their sleep.
Andrew: Maybe people should always be aware of why they're having the caffeine. If it's just...if they know it's just as a relaxing thing, as a treat or whatever, as a reward, fine. But if they're using it as a crutch for some other issue, maybe they are overstressed, unfinished work, they're trying to stay awake when they should really be getting sleep. Or indeed, as you mentioned, we might have a sugar control issue going on, is that...do you look at this sort of thing?
Norelle: Yes, indeed and I normally... When I'm looking at caffeine for people, I don't...if people are used to having their regular morning cup of coffee, that's something that you don't really want to take away from someone because people get very attached to their morning cups of coffee.
Andrew: Yes, I do.
Norelle: And so I would just be saying, "Look, are you having one later in the day because you're feeling tired?" As you said, are they using it as a stimulant kind of keep them…. Do we need to look at their blood sugar regulation? Can I support them with, you know, other means that will give them that energy? Is it about having snacks at a certain time and a certain kind of snack that will kind of get them over that needing that caffeine hit to have, you know?
And especially I think energy drinks are a more, you know, dangerous kind of caffeine to be consuming because there's a lot of other sugar and stuff that goes hand in hand with those energy drinks. And the caffeine is quite high in some of them. They have, you know, a 600 ml of...some energy drinks it's almost got 200 milligrams of caffeine.
Norelle: Yeah. so that's quite a bit.
Norelle: Ahh, yes, alcohol. And it's one that can be really hard or tricky to address in clinic in terms of people use it as a sedative to go to sleep. And it actually is a sedative. It will send people off to sleep. The problem with alcohol is that it fragments your sleep. And as the alcohol metabolises you get...yeah, your sleep becomes lighter and you're not getting that refreshing quality of sleep.
So yes, it will help you go to sleep. But it's not the best for your sleep at all. And, in fact, it's...you know, in excess it's not good for the health overall. So it's one that I, with people who are having sleeping problems, I say no more than one standard drink a night. And that's not your home pour of a glass of wine because there's no way that's a standard drink for most people. And or if they can do it, I suggest to them a period of...you're doing it 30 days sort of abstinence.
Norelle: And if I can talk them into that, it's often surprising. They'll come back to me and say, "Wow, I just slept so well and I had energy." And it's, like, they haven't realized. Because we use as, you know, a society, we use alcohol quite a bit. And probably in a reasonable amounts, I would say, for most people. More than they probably think they consume when you ask them.
Norelle: In my intake form when they...sort of I have a question about that . And I kind of almost go, "I always need to probably add about 20% to whatever you’ve put there." And that's probably what the reality might be.
But it does have a big difference, if you can get people to, yeah, stay off the alcohol. And they have found, like they've done studies, where they’ve sort of… because people have said, "Oh, if you drink, you know, if you drink/had drunk in the afternoon and your alcohol had metabolised before you went to sleep." So say you stopped drinking at 5 o'clock and then you went to bed at 10. So the alcohol metabolised. They still found that it affected sleep. They still found differences in it.
So yeah, there's something else going on there with alcohol. And, of course, chronic alcohol, heavy alcohol users can actually permanently affect sleep and brain mechanisms. So people who've had those sort of things, it can be hard to fully get them back to good sleep just because the alcohol is actually, yeah, permanently…
Andrew: Yeah. You mentioned sedative medications. And just before I go on to that something just popped into my head. And it's an old lesson that Bob Buist taught me years and years ago. I remember this from his clinical nutrition course. Thanks, a lot Bob. And that is basically these Swedish researchers... This is decades old, Swedish researchers, these weird Swedish researchers, were assessing how people metabolised coffee by, wait for it, smelling their armpits!
Andrew: And I just thought, "Who would be Swedish researcher?"
Norelle: Who would sign up for that?
Andrew: Who would sign up for that job? But I just...I remember that and I don't know you know, like, "Hey, darling I'm just not sure whether my caffeine is really interfering with my sleep. Can you just smell my armpit and just see if..." Sorry, girls. I'm just saying that would be in an interesting partner communication or connection tip, wouldn't it?
Norelle: Yeah, I might have to look up that gem and see can I get my clients doing that?
Andrew: I think I'd much prefer to be maybe doing a gene SNP test for COMT or something myself.
Norelle: Yeah, I think that's probably plenty potentially a more accurate way than relying on smell, which differs from person to person anyway.
Andrew: Yeah, that's right. So now back on track, onto the issue of sedatives and we have our medication, our prescriptive medication, of sedatives. Indeed, there are some that you can buy over the counter, the antihistamines.
Andrew: How do they work? How effective are they? Do they have any issues long-term? And how do they compare or contrast with what naturopaths would use in the herbal "sedatives?"
Norelle: Yeah, well, I think in terms of the herbal and the medical terms of sedative, they’re kind of meaning two different things. Like, in terms of the pharmaceutical one, sedative is actually meaning putting you off to sleep quickly. And there's not that many herbs that really do that.
Herbs are more tonifying or relaxing the nervous system. So there is a sort of a bit of a difference when people sort of say, "Oh, what’s something herbally to knock me out?" It's like, "It's not kind of quite to do that the same way that a sleeping tablet will do." So yeah. So that's kind of a key in terms of differentiation.
But in terms of the kinds of things that get prescribed, there's, of course, the well-known benzodiazepines. And these are...I would say doctors are probably are very cautious about prescribing them. I don't...which is great. And you know, fantastic because they are a class of medications that's very addictive. And they really do reduce deep sleep time. That's your, you know, restorative deep sleep. Where, you know, cellular repair and all that's happening so. And they've got quite high dependence. People become you know, dependent and addicted to them quite quickly. So I think they're only prescribed when there's no other option and short-term. And from what I've seen in terms of, you know, interaction with patients who maybe have been on stuff for short-term. So I think, you know, they're quite well regulated.
But the other class is the non-benzodiazepines that you see quite a bit and they're often called a Z drug because they all start with Z.
Andrew: Yes, right. I know where you're going with this.
Norelle: Yeah, Zolpidem is probably the most well-known one. And it's the one that's...it's sold under Stilnox in Australia.
Norelle: And Ambien in America. And various other things in Europe at that, but they're these kinds of the key ones that I can remember in my brain.
So they also work on that GABA pathway, like your benzodiazepines, but they're meant to be less addictive. And they are in one sense. And they're meant to be a safer form of that.
Norelle: But it's interesting, the research is looking a little bit scary.
Andrew: I've got real issues with this one.
Norelle: Yeah, really scary on these Stilnox. And there was a study in the British Medical Journal a year or so ago where they looked at the mortality of these. And even with doses between 1 to 18 a year. So that might be someone who just uses it on a long-haul flight. your risk of dying is increased 3.6 times.So that's pretty huge and it...
Andrew: Is that all-cause mortality or is that from specific causes of death, like suicide?
Norelle: That was all-cause mortality.
Andrew: All-cause mortality, right.
Norelle: Yeah, all-cause mortality.
However, there is some evidence that Stilnox increases the risk of suicide by 2.8% in studies that I've read. So that's actually...and there was one, a study, that was done here in New South Wales and they looked at coronial cases. And zolpidem was implicated, maybe not directly, but in 90 of them over a 10-year period. So it was enough that the researchers sort of said, "Listen we should look at this drug." And other research I looked at has said that when they're prescribe with painkillers, concurrently, you have the increased risk of respiratory deaths at night while you're taking them.
Andrew: We are talking opioid painkillers?
Norelle: Yeah, painkillers, opioid painkillers. And that's because of the depression of the respiratory centre and if you're a bit susceptible to that.
And often though, they did say that it's maybe not picked up because the person might be had something else going on and their death is attributed to that rather than the combination of these two medications. And it's not unusual that people on these medications have...can exhibit, you know, the parasomnias, the sleep driving, sleepwalking, bizarre behaviour where they don't remember things.
Norelle: So they'll, you know, and it's more common than you might think.
So there's a guy in America who's done quite a bit of stuff on it. And he's really like, "This is actually something we need to look at and these things, you know, how there being prescribed should be a little bit more tightly controlled."
And when you look at the benefits from, you know, what they say you get from taking these Z drugs, it's quite modest. That it reduces the time to taking it to sleep by about 12 minutes and prolongs your total sleep time by about 10 to 11 minutes so…
Andrew: Half an hour, if you're lucky. What about the issue of shift workers and the impact of biorhythms and disordered sleep on a normal diurnal rhythms? Can we...you know, you spoke about our chronotype. Should we be sleeping to our chronotype? How does that work with Western society, the pressures of performance and work? And how do we regain restful sleep?
Norelle: Yep. This is a really interesting question and something that I'm quite personally interested in, as well. And in terms of shift workers, I mean, obviously, we do need shift workers, all our wonderful emergency services staff and nursing staff.
Norelle: Even people who work in weather bureaus and stuff like that, they will work shift workers to make sure, you know, they're keeping a watch on the weather and that.
So these people, they have found that it's actually easier...shift work is easy for the owl chronotype, so the later chronotype. No surprises there really. But interesting that someone looked at that and said, "Well, these people might be more suited to shift work."
It does have real impacts. And if you talk to people who've done shift work for a long time, they're often looking...especially as they get into their 30's and 40's, they're looking to get out of shift work because they find it harder and harder to maintain the energy and get any kind of decent sleep as they get a bit older.
The research shows it really messes with your blood sugar and glucose homeostasis. Because at night, that's all going down. You're not in a point where your body's wanting to release a lot of insulin and help digest and regulate that. It's sort of, you know...it's naturally wanting to do other things. And if you eat food during that sort of, you know, after 1am, before 5 or 6am, it's not an optimal time to digest it. And there's a lot of gastrointestinal disorders that shift workers may suffer from…
Norelle: Because their digestion's not primed. And there’s some research indicates, female shift workers maybe have an increased risk of breast cancer.
Norelle: And that was a 2016 study. So I thought, "Oh, that's a bit scary," that if you were.
And they are sort of saying often that there's something to do with your macrophage function. I think the research is still really being done. But macrophage function, that actually helps regulate any, and clean up any possible aberrant cellular stuff going on, is not as effective when your working against that. And so it will be very interesting to see what comes of that research I think and...
Andrew: Yeah, you know, because that hooks into tumor-associated macrophages, the TAMs. Which are a prognostic indicator for things like breast cancer. It's very interesting.
Norelle: Yeah. I've got to admit oncology is not an area that I have a lot of knowledge in. But I sort of thought when I saw those stats and, you know, the sleep and stuff, it was like, "Wow."
Andrew: And melatonin, as well, of course.
Norelle: That is very interesting. And yeah, it's just make something to keep an eye on in terms of the research with that.
So shift workers... Look, there's very various different strategies. But I think key ones, a lot of times the workplace is not set up to really help facilitate their transition. And I think a big thing is that they have, you know, nutritious meals suited for that. Oftentimes in these places it's, you know.
Andrew: Horrible food, yeah.
Norelle: Yes, food that wouldn't be good anyway but especially not good, you know, if you're doing overnight work.
And some shift workers say they really do try and put their meals to a similar schedule to if they were on day. And just have really light healthy snacks, you know, overnight. Rather than eat a big meal that is difficult to... And they said that sort of helps them get back into a sleeping routine.
I think it's better in terms of...it depends on how often they're changing shifts, as well. So there's lots of different things that we probably need to research and look at in terms of that to look at what are the best shift change times, not necessarily the best for the company, but best for the human beings in terms of their chronotype. What kind of things the workplaces need? Do they need napping rooms? So those people can have a nap in the middle of their shift? Yeah, and how do they educate people, you know, their staff who are shift workers? Because some workplaces and companies do some of that. But there's a lot that probably don't do that, as well, to help people going onto shift work.
Andrew: How about how do you stratify your interventions? Do you always use lifestyle interventions first, then dietary, then perhaps any judicious supplements? Or do you go in first with some supplements and say, "Let's get you having some sleep first and wean you off them?"
Norelle: Yes, it kind of...it does depend a little bit on the case as it presents and how long they've had it. I'd say someone who really hasn't slept for a long time and it's, you know, it's chronic and they're tired and exhausted, I'd definitely go in probably, you know, reasonably heavy in terms of trying to get them to have some sleep. Because if you're not sleeping well, your motivation and willpower is severely eroded.
Norelle: And you want people...if you want them to do diet and lifestyle and exercise changes, like, getting into exercise, you kinda need to get that motivation up and then it will be easier for them to do it. And you don't want them to feel like they're failing and going into, you know, some kind of cycle like that. So yes, I would look at going in with treating that. And often...I had a lecturer at...when I was at uni. And they would say about sleep. And it's always stuck with me. And I think it's a pretty good general principle is that you treat the day to fix the night.
Norelle: You sort of have to look at what are they doing during the day. Especially with so many people are being affected by stress-related anxiety or mood related sleep disorders. You've kind of got to go, "How do we get you, you know, calmer during the day so that you arrive at night time and you're able to more easily wind down into a sleep state?” So that you're not in this constant sympathetic dominant state all the time during the day? And then suddenly it's excepting to flick a switch and go into rest mode and it's not happening.
Norelle: But then again there's other people who can, you know. Like, I've had people who literally have came to me and said, "Ah, Just in the last month I haven't been able to sleep well and I don't know..." And when we unpicked it, it was because they changed they're the gym workouts, so a high-intensity exercise class to the evening." Maybe we'll just...
Norelle: Change that back to the morning and call me back in a week and tell me how your sleep is going. And when I spoke to him in a week, "Oh, I'm sleeping fantastically again." So that was one where, you know, it was okay and we just changed.
Andrew: That's the KISS principle, “Keep It Simple Stupid.”
Norelle: I know, it was just like, "Oh, I feel bad taking your money for this but..." Anyway, it was, yeah, so it’s good when you get that kind of result. And you know, people can just go, "Ah, yes." So but it's not always that easy and sometimes you really do have to start digging in and unwinding, you know, different layers in terms of their health. And especially if medications are involved and there is side effects of those medications that they're influencing sleep. So it's, yeah, a bit more long-term and nuanced there so...
Norelle: I know.
Andrew: So I’m going, "Oh." So thank you so much for taking us through sleep hygiene and it's importance. Perhaps you and I will delve into some of the therapies that you employ on another podcast.
Norelle: Yeah, I'd love to. And thanks for having me on. It's been great to talk about one of my passions, which is helping people sleep better.
Andrew: This is FX Medicine, I'm Andrew Whitfield Cook.
|Your Remedy Naturopathy|
|Dr Peter Hauri|
|Dr Michael Breus|
|Clinic Resource: Guided Sleep Meditation|
|Clinic Resource: iSleep Easy [free]|
|Clinic Resource: Snore Lab|
|Dr Jerome Sarris|