Sometimes clinical intervention is necessary to help your patients achieve a good night sleep. There's an art to deciding which interventions are most appropriate for each individual patient and which herbs or nutrients need to be included in the prescription to address a client's specific needs. Should you choose valerian or kava, magnesium or B6?
In this episode Norelle Hentschel shares her own clinical wisdom in differentiating her sleep prescptions. Picking up where we left off in part 1, Norelle continues to share her passion and wealth of clinical knowledge in helping people achieve a restful night sleep. In this episode we delve more specifically, into how sleep hygiene techniques can be partnered with judicious, carefully selected nutritional and herbal therapies to quickly resolve sleep issues.
Covered in this episode
[00:38] Welcoming back Norelle Hentschel
[01:31] Recap from part 1
[02:30] Adequately preparing for sleep
[06:57] Where to begin with therapy?
[10:15] Connecting food intolerances to sleep disturbance
[12:48] Temperature fluctuations affect sleep
[16:02] Magnesium for sleep support
[25:24] Glycine for sleep support
[26:52] What about adenosine?
[29:42] The herbal prescriptions for sleep support
[48:58] The clinical outcomes of drop dosages
[50:27] Taste and compliance with herbal medicine
[55:04] Resources for further learning
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining me on the line today is Norelle Hentschel, who holds a bachelor of health science in naturopathy and has a private practice called Your Remedy based in Crows Nest, Sydney.
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 to sleep better. She's passionate about patient education and health awareness and focuses her treatments on diet and lifestyle modifications so that her clients attain their best possible level of wellness and vitality. Norelle has a special interest in the areas of sustainable food as medicine, sleep disorders, digestive health issues, and natural approaches to menopause.
Welcome back to FX Medicine. Norelle, how are you?
Norelle: Very well. Thank you, Andrew. Lovely to be back.
Andrew: And it is to be back to finish off our part two of the sleep series. So, Norelle, I think, why don't we just jump straight into it? Can we just recap on your first podcast, which was about sleep hygiene? Can you take us through the major points first?
Norelle: Okay. Certainly. So we were talking about sleep hygiene, which is all the things you do to help yourself give yourself the best chance of sleep. So we spoke about the effects of alcohol, caffeine, the environment that you sleep in, how warm your room is, how much noise there is, the effects of other medications and that as well.
So those are sort of the core things that you need to have sleep. We also spent a bit of time talking about the very prevalent thing these days is the amount of screen time we all have.
Norelle: And the knowledge that we're getting now about how it does impact our sleep.
Andrew: Can I just ask one question to flow over from that? And that is, you know, and just imagine this, you know, you have lovely, crisp sheets to get into bed. There's nothing better than getting into a bed where the sheets have just been washed and they're nice and crisp and clean. You hop into bed and then you get that weird, oh, there's a fold in my pyjama leg, you know? Or my pyjama leg isn't quite down near my ankle. You know, it's not uncomfortable, it's just this weird feeling of, it's not right. What is that? Are we talking like a SNP here? Like, what's going on? How do you overcome that? How do you take people through that so they actually drift off into sleep rather than concentrating on those weird creases in their pyjamas?
Norelle: Well, no one's ever actually asked me about weird creases in their pajamas until now but, you know, it's an interesting question and it would probably suggest that their brain's alert and they're feeling quite stimulated. Because if you're in that point where you're going down into getting ready for sleep, you're sort of not as sensitive to all that kind of stimuli. So I would sort of be looking at, are they actually ready to go to bed yet?
Norelle: You know, are they in that...you know, is their sleep drive high enough to get them to sleep.
Norelle: Or, you know, do they need a new set of pyjamas? So yeah, it would be about making sure that they do whatever they need to do to feel comfortable, you know, when they get into bed because that's a big part of it, you know, you need to be feeling comfortable.
Andrew: I guess along that line, you know, the other thing I've done is I've gotten into bed and you say, "Okay, you know, relax," and then you feel yourself. "Yeah, okay. I'm relaxed." And then you go, "No, I'm not. I'm actually quite tense." And you have to physically or consciously be aware of, even if you re-tense a muscle and then relax it, you know, the old meditation, mindfulness sort of thing?
Norelle: Yeah, yes.
Andrew: And it's amazing how many times I've gotten into bed and thought I was relaxed, but I wasn't.
Norelle: And again, that's a common thing that I get told by my patients as well, that they... as soon as they get into bed, it's like "ding." They kind of almost feel like they're really alert. And I have a theory that it often contributes because we haven't taken the time to process our day before we get into bed.
So suddenly we're in bed and we're not trying to do anything, you know, make kids' lunches or, you know, catch up on Facebook or anything like that and suddenly we have a chance, the brain kind of goes, "Ooh, we need to process all this stuff that's gone on during the day."
Norelle: And so that's when the brain starts engaging. And it can often be a nice thing to actually allocate some time earlier in the evening to kind of almost do that processing so that by the time you get to bed, you know, you can almost tell your brain, "Oh we've got that sorted, we've got our to-do list for tomorrow, we know what we're…where we're heading, and we don't have to think about it right now." So...
Andrew: So how much time do you say one should allocate for preparation for sleep? Like, getting the lists ready, getting everything in their place. Particularly if somebody's dog tired and they're just like, "I just want to go to bed, but I know that when I do my mind will play tricks on me and keep me awake."
Norelle: That's a really good question and it does vary, but I'd like to say at a minimum people should be trying to do a bit of a wind-down process at least half an hour before they want to go to bed and go to sleep. But an hour is a good idea.
So it can start off with simple things like an hour before just making sure, you know, you're getting off the laptop, you're getting off your iPhone, all that sort of stuff. You're dimming the lights in your house to sort of start to get that melatonin production happening and calm everything down.
And then you sort of, you know, you might be doing a bit of reading. You might choose to journal or even just do a to-do list. I mean, a lot of people think, oh, I've got to journal and it becomes this big huge, you know...
Andrew: “War and Peace” saga.
Norelle: Yeah, or I've got to do it right. But it can be just as simple as writing a to-do list of, you know, what do you want to start with tomorrow. So that you've got it out of your head and it's on a bit of paper.
Andrew: So today we're going to be talking mostly about sleep therapy and of course that means intervention. So when we're talking about interventions, do you always wait until you've tried every bit of sleep hygiene measure first? Or do you sometimes go, you know what, you're in a spot. Let's see if we can give you something to help you sleep now while we're doing the sleep hygiene measures?
Norelle: Yes. I'd be going with the second one. Because often what is happening if people aren't sleeping well, they're tired, they're irritable, you know, their anxiety is often higher than it normally would be. And you want to give them something to kind of break that and get the motivation. Because a lot of the sleep hygiene interventions are about making lifestyle changes and that normally requires a bit of motivation and discipline.
Norelle: Are two things that are very hard to do when you haven't had enough sleep.
Norelle: So if you can get someone actually sleeping a little bit better, then they're more motivated to make the changes, the sleep hygiene changes.
So I would sort of start with, you know, picking a couple of… after you've done a very detailed case history as you always do with any client that you're seeing, I would look at, okay, well, what for that person is a couple of key sleep hygiene things to do? I mean, there's no point telling someone to not drink alcohol if they don't drink alcohol anyway. So you really want to target that. And that's what the research has shown with sleep hygiene, that giving someone a handout of 10 or 12 standard sleep hygiene things isn't as effective as saying, "Listen, Andrew, if you do this and this, let's try these two things for the next week. And, you know, then we'll see how we go from there."
So it's really about, as with anything, tailoring, you know, the intervention to the individual in any situation.
Andrew: So I'm going to pick on you now. So over your years of practice, do you find that you've gotten better at picking the appropriate ones to focus on?
Norelle: I think so because you get better at taking case histories, the more you do, you know? And then if you're working in an area a lot, you do you know, you have a sort of a knowledge of the questions and the flow and what might lead to one thing to sort of... Because sleep is often in the case of... I mean, most of the people I see have secondary insomnia, so not the primary insomnia, which is a lot more challenging. And often is going to a referral to, you know, a sleep clinic or someone else to help with that.
But that's just all about making sure, you know, you really do dig into their case history and elicit what's going on for them, what's causing it? You know, is it caused because they're stressed, because they're very anxious, because they've got a food allergy? Or is it a side effect of medication that they're on for something else? So we look at, you know, all those kinds of things.
Andrew: Now that's an interesting one to try and tease out, a food intolerance. How do you then decide that you're going to go down that track of food intolerances? Is there a differential signal that you key into that you go, "Oh, hang on. What's happening here?" Like, the normal things, you know, the bloating, the tiredness, the dark circles under the eyes, that sort of "allergic" type of person. Or do you tend to just sort of find it as a matter of course?
Norelle: Certainly the allergic-type person, the dark circles, if there's any kind of sinus congestion or those kind of signals, you might look at if there's, you know, something else going on with that. But also, I often, or regularly get people to do a food diary as part of the consultation.
Norelle: So we sort of look at, are there things that, you know, every time they have something that's got MSG in it, they don't sleep well that night. Or, you know, certain kinds of foods that they're having at night and you go, oh, is that causing it. So you can kind of go, "Okay, let's remove that for a bit and see how the sleep goes."
Andrew: Right, right. And of course, I guess taking a food diary would twig your attention to things that aren't just happening that day, but might be happening two, three, days after you intake some food.
Norelle: And that's a really good point because when it's, you know, obviously anaphylaxis happens immediately and someone's going to know that that's an issue for them before they come and see me.
Andrew: Well, that's an allergy.
Norelle: Yeah. But an intolerance will show up, you know, 48, 72 hours later, potentially. And it can be stuff that's kind of low grade. Things like if someone's intolerant to like, salicylates, it might be just more that they're having too much of a thing…
Andrew: Yes. Any of a thing.
Norelle: Rather than that they actually can't have any of those foods. They might be just, you know, going crazy on the coconut oil and the avocados and that's not the best thing for them to have.
Andrew: Yes. Thank you for putting in that salient point. There's so many people, practitioners included, who think that… and I know I'm getting off track here, but they seem to take some notion into their mind and say, "That is all". For instance, the no FODMAP diet rather than the Low-FODMAP diet.
So back on track, Andrew, and I guess this one also encompasses sleep hygiene, but, you know, we're at the end of winter now in Australia… little better than jumping into warm, snuggly bed. But then I've often found that. "Ah, you know, it's gotten too hot," and I kick the sheets off and then it gets too cold and sort of, you know, then I got my foot hanging out and stuff like that.
Whereas my wife needs a furnace to get to sleep. You know, so the blankets are piled on her, but, you know, strangely enough, there's this flip that we're having with Lee going through her menopausal years, which is very interesting I find. But why such a difference between the sexes in their need for a certain temperature to drift off to sleep? And then how do you work in the adjustment, you know, the natural adjustment of a decrease in body temperature during, particularly the early hours of the morning. What happens there? How do you accommodate that?
Norelle: Well, it's not uncommon for bed buddies, bed partners to have different kind of temperatures. And men and women's metabolic rates are different anyway. So that explains part of the... Men tend to run at a slightly warmer temperature. Their metabolic rates are higher. Generally. All things being well. And women's are a little bit slower.
Women can also be a little more prone than men to have issues with their thyroid as well. So that sort of affects temperature and feelings of cold. But as you say, that flips as women go through perimenopause transition and, you know, the night sweats and changes in body temperature.
As well you can have things where the weather is, as well just, you know, influences, if for whatever reason it doesn't cool down. You know, I think one night in summer here in Sydney this summer we had one where it actually… the temperature increased over the night, which was really unusual. And it was like, because you normally expect a bit of relief early in the morning or to cool down a bit. Great, I'll go into a deeper sleep, but it actually got warmer. So you do have those sort of, you know, environmental changes.
The best way to kind of deal with that is to have the ability to be able to easily kind of, add more layers or take layers off without sort of, you know… A lot of times people sleep with just a doona and sheet…
Norelle: And an electric blanket, say in winter, and that can be really hard to sort of, you know, get yourself to that comfort level if you don't sort of have a couple of layers that you can kick off, pull back on, when it gets a bit cooler and stuff like that.
And I believe for the male-female thing, there's actually doonas you can buy that as sort of heavier on one side, for the females and lighter on the males
Andrew: And then you put it on the wrong way. Just to tease your partner.
Norelle: Yeah, exactly. Oh, dear. You might be sleeping in the dog house then.
So what about nutrients? You know, like theres… I'm thinking of the hero of relaxation nutrients and that's magnesium. How beneficial do you find this? Given, I think, even what is it? Australian Institutes of Health and Wellness, that's the government department, AIHW, speaks of magnesium deficiency being highly prevalent in today's society where "we all have access to good food." We're not eating it. Australia is not eating a good diet.
Norelle: Well, no. And we don't like our leafy greens enough, I think, is part of it. But the other side to that is actually a bigger about soil quality. And that is that our soils around the world are magnesium depleted in a lot of cases. So we may be, you know, even those of us who are eating a very good diet, but we may be getting 30% to 50% less than someone, you know, 100 years ago eating those same foods.
So it is a challenge. And I think, you know, magnesium is one of those nutrients that is very easy to not have enough through the diet sources. And it's certainly the core foundation, or core of the nutrient prescription for insomnia. Because it's involved in the manufacture of melatonin needed for both the SAMe and the serotonin conversions through to melatonin. Having not just your baseline magnesium, but having good levels of magnesium also helps your melatonin stay around longer.
Andrew: Ah ha.
Narelle: So if you're sort of someone in that early morning awakening thing, that can be something that magnesium can really help because it can help keep the melatonin stronger for longer, as I say.
Norelle: It also...some research seems to suggest that magnesium can bind to GABA receptors, so increasing that relaxation. And it's got the muscle, you know, so if you're sort of tense and tight, it's well known, you know, magnesium… And well, calcium is the other nutrient that you want to make sure is, you know, in a sleep prescription. So yes, magnesium is definitely one of the big ones there. So yeah…
Andrew: Do you adhere to this two to one calcium to magnesium ratio?
Norelle: I think it is important because nutrients when you're getting...in terms of nutrients as a whole, as a general philosophy because the ratio that are found in foods and that, you know, you would assume evolutionarily is an ideal way for us to consume nutrients and make sure then that we're not knocking one thing out of balance by having, you know, mega amounts of another one.
Andrew: Yeah, but see I've never found that two to one calcium-magnesium ratio in any food. Not that I've looked exhaustively, but the few that I've looked at, they're never that way. However, I've never also assessed how you put that together in a diet. So you don't just eat one food all day. You tend to put different food groups together. So I've never also assessed that as well.
Norelle: Yeah. And it's a complex thing, nutrient balance. And that's why, you know, a dietary prescription is often going to be the ideal if we had good soils and all that way to, you know, get our nutrients into our body because it's going to have that balance across the board.
Norelle: But, you know, I don't know where the two to one ratio kind of originated from, probably it'd be interesting to sort of look back and see where that came to be.
Andrew: Well, intracellularly it seems to be that.
Andrew: At least in a resting state. But, you know, there's elegant control mechanisms within our cell, you know, the sodium-potassium pumps, etc. So I don't know, I'm undecided about that. It just seems to be funny that we want it in a tablet and I think, really?
Norelle: Yeah. And look, a lot of formulations that you get don't...sort of some have… some have that ratio but a lot don't actually have that ratio either. So yeah, it's interesting that those companies may not sort of, you know, put as much emphasis on that kind of ‘old school’ rule that seems to be around there.
Andrew: What about forms of magnesium? Do you prefer one or the other? Like, I know that the German research, for instance, favours magnesium citrate and that has some certain benefits. You know, there’s, in Australia, the magnesium bisglycinate or diglycinate seems to be the hero one, you know, largely because of commercial interest telling you it is. But it'd be just be really interesting if somebody has actually done, for instance, you, have actually looked at how the administration of these nutrients cause response in your patients. What do you prefer?
Norelle: Well, I have used both and I have found both to be effective. So, you know, I think they're both forms that are really well absorbed generally. So, you know, absorption is a problem for a lot of people. So to give them anything that's going to absorb... And if they're someone that's quite low in magnesium anyway, I think either of those forms are going to give them some benefit.
So I haven't sort of noticed one more than the other. I would probably be using more of the, like, the amino acid chelates and biglycinates, just because a lot of the products actually have that as a formulation.
Norelle: Whereas the citrates tend to be on their own and often you're prescribing magnesium in a formulation with other nutrients that support it, for example, your B group vitamins and that.
Andrew: Yep. Just on that line, I've had one lady in my whole career who said that this infinitesimal amount, I think it was something like 3 milligrams or 1.6 milligrams of B6 kept her up at night. She swore black and blue that that's what it was. Of course, it was in a multi. But anyway, that was her edict, whatever. How big an issue do you find this B6 hyper-alertness at night thing to be? Do you think it's only with large doses or is it certain types of patients?
Norelle: Look, it's probably certain types of patients more so than others. And I'm sure it's probably, I haven't looked into it, but I'm sure it's probably to do with, you know, genetic variability and certain SNPs…
Norelle: And it could even be down to like liver function and differences in that, that would have it.
Andrew: Ah, good point.
Norelle: But I do know that some people don't react well to B6 or B vitamins in general in the evening.
Andrew: Ahh, okay.
Norelle: It can tend to stimulate. So I tend to, I suppose err on the side of caution of prescribing and doing formulations with B vitamins sort of in the day and then, you know, if you’re after magnesium for night, looking at one that didn't have the B vitamins in it for a night time one.
Norelle: But then you've got people who can, you know, have quite large doses of B vitamins at night, it doesn't affect them. It's like the people who can have an espresso after dinner, double shot and say they sleep like a log.
Andrew: Yeah, yeah.
Norelle: So, it really is, I think it's probably down to genetics and how their body metabolises different things.
Andrew: Yeah, of course. I guess my sort of idea of it would be to lessen the B vitamins and not necessarily be so hell-bent on avoidance. And I guess my thinking there is because hey, evening meal’s got B vitamins in it, right?
Andrew: So, but what I'm not talking about is these fifty, hundred milligrams. You know, I agree with you, that we should avoid them at night. I just think it's easier. You know, it may or may not affect them, but it's just easier to say, "Look, take this sort of thing in the morning because it's higher in the Bs, but at night take a… you know, if it's a multi, I'm not worried," but except for this one lady. She swore black and blue.
Norelle: Yeah. And, I mean, you will get outliers, you know, amongst if you're working with enough people, you find people who have sort of reactions, you go, "Wow, I've never seen that before." And then there are the more common ones, but yeah, I mean, as you said, there's B vitamins in food and a multi is probably not much of an issue, but certainly a large dose.
Norelle: Yeah. I generally would not be recommending people get that.
Norelle: The other one I'm really liking at the moment is glycine.
Norelle: I find that it really helps people who aren't getting that restorative sleep. Like, they might be sleeping, but then there’s the type that goes, "I just wake up and I feel fatigued. I don't feel like I've slept well." And it actually, when I did some research on it, it increases growth hormone release, which is at night. That's one of the things that helps repair and regenerate. And it also has a bit of interaction with your circadian rhythm as well.
Norelle: It influences some of the genes and that, and works with serotonin, which you need a little bit of serotonin for sleep, not too much, otherwise you'll be very stimulated but a little bit helps sleep.
So yeah, getting some quite good results with that kind of person that's feeling really fatigued in the morning. Of course, there's many other reasons why you can, you know, not feel refreshed and that, if you've got adrenal stuff going on as well.
Norelle: But yeah, that can be a nice... And it actually helps people go off to sleep, yeah, faster than they normally would as well.
Norelle: I have used adenosine.
Norelle: And I love the theory of adenosine, but I haven't seen the clinical results. And that may be...and also a lot of the formulations, they don't have a very good taste to them.
Norelle: So compliance can be a little bit of an issue, but I also know other people who have found it really good. You know, it's just that sort of variability with different things
Andrew: I don't know how to tell them apart though. Like you, I've had a couple of people that found a wow effect and it was really quite marked for them.
Andrew: They felt quite drowsy and very quickly too. Like, we're talking half an hour, but it didn't work on all patients at all.
Norelle: No. And I think well, adenosine, what it's doing is increasing that sleep drive. Because that's what should happen during the day as we go along.
Norelle: If we don't sabotage it. Is that your adenosine is building up in the brain and it reaches that point where you just, you start to feel really sleepy. And that's your maximal sleep drive because you've been awake. The longer you're awake, and if you're not having caffeine, the more adenosine should be building up.
So in the people who, for whatever reason don't get that build up, I think adenosine can be really useful to help get that sleep drive happening.
Andrew: Yeah, it'd be interesting to look at the data and, you know, which sort of patient group this might suit bitter. I don't know? I've never looked into it.
Norelle: I think again, it's that person who maybe doesn't necessarily feel as sleepy. It might help... It'd be interesting, I'm starting to sort of look a bit more at chronotypes and that kind of thing. Where people have this delayed sleep phase, you know, kind of thing. So it may be useful in that in kind of tricking the brain to think that the sleep drive is higher if they would normally need another couple of hours to get to that point for whatever reason.
Andrew: Anything else? I've never used SAMe, it wasn't around in my day. So I've never used SAMe for sleep, have you found that useful?
Norelle: I don't tend to use it as a... It might be something I'd have in the back of my mind for a certain kind of person with sleep if there was some depression in the picture, methylation kind of things going on, I would consider it. SAMe can be sort of an expensive one.
Norelle: In terms of cost, so it's not normally the...but it can be really effective, but it's not the first one I would probably jump into in terms of a sleep prescription.
Norelle: Oh, well, it's one of my favourite ones as well.
Andrew: How long have you got?
Norelle: So in terms of the herbal prescription, I suppose, a way I look at it is to look at a day and a nighttime prescription.
So, some kind of actions that I'd be looking at for daytime kind of things is, your nervines, your adaptogens, adrenal tonics, anxiolytics as well, in terms of those kind of herbs. So to sort of try and support people's energy and nervous system to have that calming effect but not sedating effect during the day. And also I prefer not to do anything that's too stimulating herbally during the day. Because that can kind of rev people up and then it's sort of almost harder to get them to come back down for relaxation and recovery mode.
Andrew: So even though they're tired, you know how people they want a hit, do you sort of say, "Hey, back off a bit, you know, we really need to prepare you for this and even you out rather than, you know, stimulate...” You know, the old, what is it, the '70s thing of taking an upper then a downer. We need to even out that sort of biphasic approach. That's a really wishy-washy way of saying it, but...
Norelle: My feeling is to try and build up the energy, but not sort of give someone an artificial… not that herbs are really so full on in terms of... it's certainly not like taking an upper, or so I would be led to believe.
But, yeah, to sort of look at tonifying the nervous system and, you know, gentle adaptogens to get that, release that, you know, adaptation energy. And help them build up with, you know, diet and all that kinds of things as well so that they maintain energy.
And some of that is also looking at, and I'm increasingly finding this with sleep, is there's correlations between blood sugar and insulin imbalances. And so that whole metabolic aspect of being imbalanced metabolically and obviously because that's driving your energy cycles, one of the things that's driving your energy cycle. So to try and get people to have that nice, smooth, good glycemic control throughout the day and not be sort of spiking up and down. And, you know, running on stimulants is a sort of the key part of that.
So things that I like to use during the day, are Rhodiola as HPA axis regulator and adaptogen. And Withania, especially if they're sort of really debilitated and low in energy and got a bit of anxiety. And Withania is a nice one to carry into the nighttime prescription as well. So you've sort of got a bit of a continuity through there as well. Because it's got that slight sedating aspect to it. Not strongly. It's very slight.
Norelle: But it's not going to stimulate someone at night. And of course oats is lovely as well during the night.
Andrew: Ah, the oft-forgotten oat.
Norelle: Ahh, the good old oats. It's a lovely one. It's not a fast working one. I tend to find it’s, you know, more the… have someone on that for a month, but it really starts to kind of build up and do some nice things to the nervous system in terms of balancing it out.
Andrew: What about though, you know, things like Korean ginseng, the Panax ginseng, which, you know, most people, most natural health practitioners would term it a ‘stimulating ginseng.’ But even Korean ginseng, like, admittedly if you take a lot of it, like an idiot, like these ginseng abuse athletes, it's going to cause stimulatory effects, but a little bit. Do you find it's an issue, or do you find that you just choose it in those people that are really debilitated?
Norelle: Yeah. And it is about finding the right... I mean traditionally in Asian cultures, that ginseng was prescribed for the older person as a tonifying thing. And I think that's got a lot of value in terms of how to think about using that, you know? Not necessarily going, you know, as you say, with the athletes, the hardcore, we're going to megadose on, you know, Korean ginseng.
And the other one I might often use during the day is Kava. I find it's a really nice daytime prescription. It's not sedating. It can help people cope with better, be quite clear-focused, especially if they've got a lot of stuff going on. They've got a lot of things they're juggling for work and, you know, multi-tasking kind of things that they have to do. It can be a nice one to help support the overwhelm and that as well.
Andrew: Yes. And we can thank the research of Jerome Sarris, Kerry Bone and Reg Lehmann for getting Kava back onto the Australian market. Thank you, guys.
Norelle: Yeah, very grateful for that. It certainly would be an absolute tragedy to not have access to that, that herb.
Andrew: Seriously, it would be one of my 20 herbs that I could not open a clinic without. No way. It just works so well.
And thank you, Jerome Sarris, by the way, for showing that it, you know, it doesn't, at reasonable dosages, normal dosages, it doesn't have effects on, you know, things like reaction time and driving and machinery operating and things like that. But I do take the salient point that if someone's really tired and you take something that's going to help relax them, that tiredness might prevail during the day for a while. Do you agree with that sort of thing?
Norelle: I think there is that, you know, there's that rebound sort of as people start to actually relax, you know, that's when you can actually feel tired. And in some ways, that's a really good sign. It means the nervous system is relaxing and it's saying, "Hey, I want some sleep, I'm ready for it…”
Norelle: “Let me have it." So that's fantastic.
And so for nighttime, I suppose if I was wanting to get someone who's having problems going to sleep, I certainly would be looking at your California poppy.
Andrew: Ahh, yes.
Norelle: Hops, it's got a pretty strong taste in a liquid. And of course the valerian. So either valerian or I tend to use a lot of Mexican valerian.
Norelle: In my clinic. And I really love Lemon Balm.
Andrew: Ahh, Melissa, yes.
Norelle: Again, an old-school kind of herb. But I find it does work really well in night time formulation, and it works really well as a tea.
Andrew: Ahh, nice.
Norelle: Yeah. It is a nice one to combine. And not to forget good old lavender as well is a nice, relaxing one. It's often used as essential oil
Norelle: In the research. That's what a lot of stuff has been done on the research.
Norelle: But again, a little bit of lavender in a tea, mixed with lemon balm, maybe a little bit of valerian. Some people would say valerian doesn't work so well as a tea.
Andrew: But the classic one is, like, people very commonly say ‘old bed socks,’ but if you get nice, fresh valerian, yeah, okay, there's that background, let's say it's a base note, but you can get this real aromatic smell coming through. It's really lovely.
Norelle: Yeah. I actually don't mind it. Maybe it's me? Maybe I'm just used to taking a lot of herbs that sort of have different smells to it, but yeah, I don't find it...especially if it's mixed in with some other herbs and that, I find it can be quite a nice one to get people off to sleep.
Norelle: The Mexican valerian is a stronger, I would say a stronger sedative. It has a lot more of the…one of the sedating principles. There's a, well, there's probably quite a few sedating principles to valerian that we don't even know about yet. But one that we do know about is the valepotriates. It's got three or four times the amount roughly than your standard valerian.
Of course, that's going to depend on growing conditions and all those kinds of things. And as well it doesn't seem to have the...some people can get that paradoxical valerian reaction where it stimulates them. And the Mexican valerian, it seems, to be less likely to do that for some reason, and I'm not sure why that is? But it seems to be safer in terms of that reaction.
Andrew: So, if it's higher in the... I think the salient lesson is if Mexican valerian is higher in the valepotriates and if you don't seem to get this weird action side effect in some people of flipping and getting them hypersensitive, forgive me, hyper-stimulated, then we should stop blaming valepotriates for this hypersensitivity. You know? We should look at the whole herb's action rather than one ingredient.
This is my issue with standardisation. It leads us down the wrong track. We start to reductionise, there's my word for the day, everything into one chemical component rather than the broad action…
Andrew: Of, you know, the various constituents of a herb, which can be really complex.
Norelle: Well, they're so complex we don't even know that the full…you know, what all the constituents in them do exactly. But there's, you know, the other sedative principles in valerian is your valerianic acid and there's flavonoids as well, that you know, act on serotonin receptors that would also be feeding into the sedation process. So it isn't just the one constituent that's, you know, going to be having that effect.
Andrew: Yes. That's right. This goes back to many years ago when the "active" of St. John's wort was the hypericin. And then, you know, three, five years later, oh, no, hang on, it was the hypericins. And then another three, five later it was the hyperforin. And then it was this. And now when you look at the Ze117 extract, it’s actually… the scientists over in Germany that… the phytopharmaceutical company who make that, Zela. Are actually questioning whether it's the flavonoids that might be having a major action, not necessarily the only, but a major effect of the antidepressant action.
So I just think we are being so reductionist if we think that one “hero” compound is going to be the active of a herb rather than giving the honour, if you like, the respect to the whole herb and I think this is so important to grasp a hold of.
Norelle: Yeah. And it is a really important concept and I do come from that same stance as well where I'm very much about the whole herb. And it can be like minor constituents supporting these sort of ‘big guns’ constituents, so to speak in their thing. You know, and taking them away is going to change how that herb and the traditional use, you know, and what it can do. And it's a shame when herbs, I think, get put into a category, you know, St. John's wort is for depression because it's actually got a lot more to that herb than just for depression.
Norelle: And we can tend to just narrow our focus down on it. It's like saying valerian is just for sleep. It's actually a really great antispasmodic as well.
Andrew: That's right. And likewise with kava. You know, people think it's for anxiety. The research is really compelling on anxiety, generalised anxiety disorder. But people think it's a sleep aid and they're really pigeonholing a beautiful herb that can help people.
I guess I'd really like to investigate also, do you use any of the "old herbs," the chamomiles, the blue vervain, the clary sage, jujube, Zizyphus…
Norelle: Yeah, definitely.
Andrew: Do you use these herbs and what do you find their effect to be? Do you tend to use them in combination or as the hero out of this or...
Norelle: One that I'm getting some good results with is Motherwort.
Andrew: Ahh, yes, yes.
Norelle: It is a lovely one for if there's that kind of palpitations, heart things, with anxiety. It can just be a really nice addition to a formula. And of course chamomile is, you know, it's known as the mother of the gut, but it's also, you know, the gut and the brain are connected.
Andrew: Yep, yep.
Norelle: So it's a lovely one that you can certainly add to formulas especially, you know, kid's, you know, formulas. If there's a bit of restlessness going on, that with lemon balm is a nice one.
Zizyphus as well has that nice aspect for menopausal or any kind of night sweats, it can be quite helpful in that regard. Hawthorne, even as well. You know, again, for the cardiac antioxidant sort of component as well. It can also help in a sleep formulation if someone's got that kind of hypertensive sort of aspect to it and help things relax and going to sleep. So, yeah, it can be nice. And of course I often find for perimenopausal women, your Cohosh...
Andrew: Yes, of course
Norelle: It's not really sedative or that, but it's helping support the underlying cause of the sleep disturbances. Regulating that oestrogen, serotonin kind of curve balancing that all out as well.
Andrew: Speaking about balancing, there's one more herb that I think I would get shot by Professor Marc Cohen if I didn't mention, and that's tulsi, holy basil. Do you use that at all?
Norelle: Yes. I would tend to use it as a tea, that one. But it is available as a liquid in Australia now. And I shall be probably experimenting with it more in a liquid thing, but I do use it quite a bit as a tea. And it's one that, again, I like to give people that as a tea for the daytime, to sort of just have that nice, you know, relaxation effect through the day. Get the nervous system, you know balanced, relaxed, but not sedated, just for the day.
Andrew: Yes, yes. Beautiful other actions though with the immune system. I love that herb.
What I find that was funny was after Marc Cohen and I spoke and he glowed, he effused about the actions, the wonderful actions of holy basil. It really got...it was...really tickled his funny bone about this. And I had a great conversation with him. It was so wonderful.
But I immediately went out and purchased on eBay 200 seeds. They're minuscule these seeds and I thought I'm going to grow my holy basil because Marc Cohen said that there was this whole celebration about having the plant and even giving it as a gift. And so you could grow it, you could have it on your kitchen bench and you could give one as a gift to a friend or a birthday who might be in need of something. And so I thought I'm going to do this. So I bought 200 seeds on eBay, cheap as chips, and I planted them and not one flowered. I must try again this spring.
So if anybody's got some hints and tips out there about how to grow tulsi, please let me know on FX Medicine. What else…
Norelle: Otherwise, you won't have any friends.
Andrew: No, that's right. What else do we have to consider?
Norelle: Of course the other one that I haven't mentioned, and it is one of my favourites is passion flower.
Andrew: Of course.
Norelle: Yeah. And that is just the kind of the go-to. I sort of think of it as the people that have those circular thoughts that go around and they might go to bed and, you know, suddenly everything's… they're solving the problems of the world that haven't even happened yet, and you know, they're replaying what went on during the day. They're thinking about things that may or may not happen in the future. And it is a wonderful nervine and anxiolytic and just helps give a deeper sleep. And it targets anyone that's got that kind of anxiety edge and it's a nice one you can also use during the day. And you can use passion flower… it acts very quickly.
Norelle: It's one that I'll often give as a simple, so that if people wake up during the night and the brain starts kicking around, they can just have a little top up, you know, at 2 a.m. in the morning and that might help them go back to sleep.
Norelle: So it's a lovely one and it works quite nicely as a tea as well.
Andrew: I was speaking to a practitioner once who was... He used high dose passion flower. And I do believe it was for anxiety? Have you ever had that experience, yeah?
Norelle: Oh, look there is... Probably, if you had someone who was kind of having a very acute attack, that would be a strategy you could look at.
I tend to sort of go on the lower end of dosing scales as a personal thing. And I have seen some people with passion flower for anxiety and I'll often give people a range of a dose that they can use. And sort of... It kind of gets them involved a little bit more and listening to their body as well, which I like. But I might say you can take between this much and this much and start on the lower end and, you know, if you need to a bit more. And often they find their doses on the lower end.
Andrew: Yeah, I used to think that. But now, let's look at the evidence with Iberogast, shall we? That's drop dosages guys. I really think we need to reassess our dosing and how people respond.
Norelle: And there's so many theories. You talk to different herbalists and naturopaths.
Norelle: You know, some people advocating, you know, gross dosing, drop dosing and then there's in between. So it's an area that... It would be interesting to see what the research actually showed.
But again, you're also dealing with individual variability of metabolisms and, you know, what other concurrent conditions they've got. So that's also going to affect that as well. So it's probably a case of, as we always get back to, of tailoring it for the person sitting right in front of you and looking at them.
Andrew: Yes. But I don't think we can dismiss drop dosages when we had the greats of herbal medicine Australia, like Dorothy Hall using drop dosages for decades.
Norelle: Yeah. And there's quite a few practitioners that just work on drop doses and get really amazing results. So I think it's definitely…there's something in it as well.
Andrew: There's one aspect I must cover and that is; fluid extracts. I remember, it was a housemate before Lee and I got married, he used to live with us. And Tony had some issues sleeping and I remember giving him a herbal formula and he said, how could anybody drift off to sleep when you're lying in bed on your side with a winced face with this god-awful taste in your mouth? How do you get people over that taste issue of fluid extracts?
Norelle: To be honest, I actually don't have so much of a problem with that. Some people will say, oh, it didn't taste great, but you know, I know it's really helping me, so I kind of..."
Andrew: They get over it.
Norelle: Yeah. And I always say to them, they can take it in a little bit of juice or that. But I think most people just take it straight, you know, not diluted in water. And it's often, it's weird, but often as the more they sort of take liquid herbs, they kind of get to almost, maybe not like, it’s too strong a word, but they get used to that taste, to that sort of plant taste of the herbal extracts.
Norelle: So it's, yeah, it's not something I've had so much of an issue with. And look, if there is someone like that, there are some tablet formulations that you can look at.
Norelle: I mean the advantage of having the liquid is you can get a very personalised prescription. Which you can't do with the tablets.
Norelle: Yeah, that's a really good question and it's one that people probably don't think sleep may not have so many red flags, but there are some key ones.
So of course any kind of uncontrolled hypertension is always, you know, a referral back to a GP to look at management and further investigation.
Norelle: Again, if there's heart palpitations and stuff like that. A big one is snoring. If they are a regular snorer, I mean people can snore if they've had a little bit too much alcohol, one-off kind of thing, but if it's a regular thing and especially if they're not getting refreshed sleep... There's actually a kind of a questionnaire or adaptation I use is the Epworth Sleep Scale which was developed by an Australian, and it specifically looks at daytime fatigue.
So if someone's sort of gets, you know, a certain score on that, I would sort of think, oh, that person may have sleep apnoea and should get assessment in a sleep clinic. Because that is something that can have very serious consequences if it's not treated. If they were having episodes of fainting or blacking out, that would be another one.
If they'd also...if they weren't sleeping and, you know, your clinical investigation sort of revealed that there had been some kind of concussion or head knock or car, you know, they'd been involved in a motor vehicle accident, I'd probably…I would be sending them back for...
Norelle: To look at, you know, there's some kind of inflammation in the brain that's affecting sleep centres and all that kind of thing.
Of course, if they're falling asleep during the day doing things that, you know, like just at their desk or they're kind of randomly doing that kind of the narcolepsy kind of scenario that should be... And anything where there's indications of really, you know, severe anxiety, depression, any self-harm or a suspected drug abuse that's contributing to that.
Andrew: Salient advice.
Norelle: But certainly the one that's probably the most one I would see, is the snoring component and making sure sleep apnoea is not involved in that. Because that can be a real issue, especially if they were to go and self-prescribe some sleeping tablets and that.
Norelle: Because if their respiratory centre gets depressed it can be, you know, it can result in death ultimately if someone's got that co-concurrently. A lot of people think snoring is just annoying, but it is a symptom that should be checked out and evaluated.
Andrew: Yes, sure. And so just a last quick question, Norelle. Where can practitioners get some really good resources around sleep. Not just sleep hygiene but sleep interventions as well or management?
Norelle: Okay. There's not a huge amount kind of out there in one package. I sort of have gained mine... There's a really great book about assessing different sort of sleep stuff by Carmel Harrington. I think it's called A Good Night's Sleep. But I can certainly send you the details of that if that's not the correct...
Andrew: Great. Yeah, we'll put the link up on...
Norelle: She's an Australian sleep researcher and scientist.
Norelle: She has some really great ideas for clinical questionnaires and things like that. And the book is a really interesting book to read and yeah, I certainly got a lot of stuff out of that for a clinical kind of scenario.
Andrew: Excellent. We can put that up on the FX Medicine website for our listeners as well. So fxmedicine.com.au, just go there and you can search for the podcast and you can find the relevant research and resources there for your use.
Norelle: So one thing I would just sort of really kind of point out is that try and think of the insomnia as a symptom rather than a cause. Of course, you're going to help manage them to get to sleep, but, you know, always look to dig further into why that person is having sleep issues. Which I'm sure all good, you know, health professionals would be doing that anyway.
Andrew: Yes. But your guidance here is really opening my eyes up. We're so busy. We're so caught up in what we think we see in front of us that we might miss some real key issues that, you know, even if it's to alert us to say, oh, I'm not sure whether I want to treat this or whether you can delve further into a patient's case history to get more meaningful data to make a better prescription that will work better for them.
So you've given me, let alone our listeners, you've given me some really great information in these last two podcasts to really learn from. So I really thank you for that, Norelle.
Norelle: My pleasure. It's been great talking about sleep. It's one of my passions. So yeah.
Andrew: It's one of my passions too, and I’ve got to say I certainly want to swap that lopsided doona around on my wife. Try that out for a joke.
Norelle: Oh, no. Apologies to your poor wife in advance from me.
Andrew: Norelle Hentschel, I thank you so much for joining us on FX Medicine today. Your insight into sleep hygiene and sleep interventions has been invaluable. Thank you so much.
Norelle: My pleasure.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.
|Your Remedy Naturopathy
|Epworth Sleepiness Scale
|Dr Carmel Harrington: Sleep for Health