Sleeping with Supplements

Hopefully you caught last week’s post about sleep for health. Dr. Ford shared some great tips to take charge of your sleep. This week Dr. Ford is back to talk about the use of supplements and food to augment our sleep!

Which boat do you find yourself in:

Confused by the myriad of choices when you walk down a supplement aisle
Owner of a pantry full of teas, leaves, and pills?

There are many supplements on the market that are promoted as sleep aides, but are they worth your money and time? Today we will review some of the most common ones to give you basic information about where to start. Please remember, however, that you should always discuss any supplements you are taking or are interested in taking with your doctor and pharmacist so that they can assess if it is right for you.

Also keep in mind that while the FDA does regulate supplements, they are regulated differently and less stringently than drug products. Therefore, it is best that you purchase from a reputable brand that is verified through a third party such as United States Pharmacopeia (USP) or ConsumerLabs.

Minerals and Vitamins

Magnesium

Magnesium is my favorite! It serves as a natural relaxant and deactivates adrenaline. It can also increase GABA, a neurotransmitter important for promoting sleep and relaxation (see section on neurotransmitters below). A deficiency can cause difficulties with both going to sleep and staying asleep.Your body cannot produce magnesium so it must be obtained through either food or supplementation. There are a variety of supplements on the market but for some people, they can cause loose stools, nausea and/or upset stomach. This problem doesn’t occur when eating magnesium rich foods. Focus on adding nuts and seeds, dark leafy greens, fish, bananas and avocados.

Calcium

Low calcium can cause sleep disruptions such as frequent awakenings in the middle of the night, leading to non-restorative sleep. Calcium is needed to convert the amino acid tryptophan to serotonin and then to melatonin. I recommend getting your recommended daily intake (1000mg for most adults, 1200mg for women >50 and men >70) through dietary sources. Sources of calcium include: dark leafy greens, dairy, seeds, sardines and salmon, legumes, and almonds. Remember, more is not better; studies have found adverse cardiac outcomes if people overdo calcium supplements.

Vitamin D

Vitamin D is the wonder vitamin that we now consider a hormone, as more and more benefits and mechanisms of action have been discovered. In addition to its role in bone health, it is important for proper immune function, cancer prevention, mood regulation, and sleep. Studies show that Vitamin D deficiency is associated with sleep disturbances, decreased sleep duration and poorer sleep quality.

Vitamin D is mostly made through sun exposure via UVB light. This is the same light that is blocked by sunscreen to prevent burns and sun damage. There have been theories that widespread sunscreen use has contributed to the increased prevalence of Vitamin D deficiency in America. This has not, however, been substantially proven in studies. Therefore, continue to wear your sunscreen (Dermatologists recommend at least SPF 30) while getting regular sun exposure, aiming for 10-30 minutes of midday sunlight several times a week. Most Americans do not get enough sunlight in the winter months to make vitamin D. In addition, if you have darker skin, are over the age of 65 or are overweight, you are at risk of a deficiency.

Vitamin D is also found in some foods, however, is difficult to get through diet alone. Some foods to be sure to include in your diet include fatty fish, beef liver, cheese, cod liver oil, eggs and fortified foods (e.g. orange juice, soy foods, some dairy and cereals). Even with proper eating and time in the sun, some people need to take a supplement, depending on individual levels. The US Institute of Medicine recommends a daily intake of 400-800 IU.

If you are at risk of deficiency, however, higher doses are recommended. If you haven’t had your levels checked and were prescribed a supplement, be aware that the safe upper limit, according to IOM, is 4,000IU per day to reach or maintain optimal levels. Because Vitamin D is fat soluble, it is best absorbed when taken with a meal or snack with (healthy) fats. In fact, taking it with your largest meal of the day may improve absorption.

Vitamin B6

Examples of healthy fats include nuts, seeds, avocados, and eggs.
Vitamin B6, a water-soluble vitamin, also aids in the production of serotonin and melatonin from tryptophan (that nutrient found in turkey that supposible makes you sleepy after Thanksgiving dinner). Due to lower levels of both neurotransmitters, a deficiency can therefore lead to poor sleep, as well as mood disorders such as anxiety and depression which can also cause sleep difficulties. Foods high in B6 include flaxseeds, fish, bananas, avocado, spinach, eggs, legumes, and sweet potato.

Neurotransmitters and Amino Acids

Melatonin

Melatonin is commonly known as the “sleep hormone”. There are, however, numerous functions. It regulates the sleep-wake cycle, regulates blood pressure, serves as an antioxidant and may also play a role in reproduction. Phew! That’s a lot!

Many of us are deficient in melatonin due to constant artificial light exposure, and chronic diseases. Many over the counter and prescribed medications can also suppress natural melatonin production. People often respond better to lower doses so I usually tell people to start low (0.5-1mg) and go slow, working your way up to 3mg max. Why do I recommend 3mg max when they sell up to 10mg in the store? Too much melatonin can actually disrupt your circadian rhythm (sleep-wake cycle) and cause you to wake up earlier than intended while also causing prolonged drowsiness during the day. That’s right…too much of a good thing can be harmful.

Higher doses can also affect some people’s blood sugar and some studies show that it may be pro-inflammatory for those with autoimmune diseases. Melatonin is, however, one of the more benign agents when compared to OTC antihistamines or prescribed medications. Whether or not you should take it should be a part of a conversation you have with your doctor. Of note, melatonin is not recommended during pregnancy, breastfeeding, for those with liver problems or those who are on warfarin.

GABA

GABA, the primary inhibitory neurotransmitter in the central nervous system, has been shown in multiple studies to play a role in chronic insomnia. Reduced levels have been associated with a hyperarousal state and mood disorders. GABA is the target for drugs such as xanax and valium, and is also activated by alcohol. A randomized controlled trial demonstrated that GABA supplementation may improve both sleep quality and efficacy without serious adverse events. Supplements can be found in tea format or capsules. Doses between 100mg-200mg have been studied. More studies, however, are needed to establish their efficacy in treating insomnia.

Serotonin

So what’s the big deal about serotonin? Serotonin is sometimes referred to as “the feel good hormone”. It is targeted by many anti-depressant and anti-anxiety medications and as previously discussed, mood disorders may be underlying causes of insomnia. Serotonin is also a precursor to melatonin, thus adequate levels of this neurotransmitter is crucial to the sleep-wake cycle. While there is no direct supplement for serotonin, there is a supplement called 5HTP on the market that I will talk about next. BONUS – serotonin can be increased naturally through regular physical activity, spending 10-15 minutes in the sun daily, and positive thinking!

5HTP

5HTP is an amino acid precursor to serotonin. 5HTP has been touted as treatment for mood disorders and insomnia. Studies, however, do not support the use of 5HTP alone for treatment of either conditions. In fact, 5HTP may deplete other important neurotransmitters involved in mood regulation, such as dopamine, norepinephrine, and epinephrine. It is, therefore, not recommended for long-term use or for those with depression.

L-Theanine

L-Theanine is another amino acid demonstrated to be involved in sleep and mood regulation, as well as cognition. It promotes sleep by increasing GABA, serotonin, and dopamine. It also enhances alpha waves which are associated with “wakeful relaxation”. The dose that has been studied and found to have benefit is 200 mg/day.

Herbs

Tea

Teas marketed for sleep often contain ingredients such as chamomile (which can be very relaxing at night), lemongrass, lavender, or valerian root. These have all been shown in preliminary studies to promote sleep, however, has weak evidence. The amount in teas are relatively low so drinking this tea before bed is overall benign and can be a great addition to your night time routine. Valerian root, in addition to being readily found in teas at your neighborhood grocery or drug store, can also be purchased in capsules or tinctures. Studies have been inconclusive regarding whether or not it helps to improve sleep quality.

CBD

Cannabidol (CBD), from the hemp plant, is certainly the hot new craze! New shops and stands seem to have popped up at every shopping center, mall, and even some airports. CBD works on your own endocannabinoid system and can be helpful in reducing pain, anxiety, and improving sleep quality. Some side effects may include appetite and weight changes, diarrhea, and fatigue. Laws vary per state, varying from CBD not being legal to requiring a prescription from a health care provider to being open to all. In some states, you can just walk into the store and purchase CBD products without concern. Be sure to check out your local laws. CBD is not regulated by the FDA, so before purchasing, it is important to research their history and find a company that has been tested by a third party.

So does it work? Well, more research is actually needed to determine how exactly CBD affects sleep. CBD may interact with some medications, therefore, it is important that you talk with your provider to see if CBD is right for you.

Food

I mentioned some important foods above to increase your daily intake of necessary vitamins and minerals. You should also be aware that certain foods can cause sleep issues due to their role in digestion.

For some, spicy foods can be a trigger for acid reflux and indigestion. It should therefore be avoided, specifically at night time since laying down can make acid reflux symptoms worse. When you lay down, the acid travels upwards into the esophagus. The same can be said for foods high in fat, another rigger for acid reflux.

High-fat diets may also cause dysregulation of orexin, a molecule that plays a role in the sleep-wake cycle.

Heavy meals and protein-rich meals close to bedtime cause your body to focus on digestion rather than on sleep. We don’t need to unnecessarily give the body anything extra to do other than rest and restore at nighttime.

Lastly, as a reminder, remember to avoid caffeinated beverages, such as coffee, black/green teas or sodas, too close to bedtime. Caffeine has a long half-life, which means it takes hours to break down from the total amount you took to half that amount. This is why some people notice coffee after LUNCH makes it hard to sleep. Pay attention to your body and respond appropriately! If you can’t figure out why it’s hard to sleep, this is the first place to look.

Bottom Line

You may have heard some of the controversy regarding supplements given that new guidelines from the American Academy of Sleep Medicine recommends against natural supplements due to weak evidence. Keep in mind, the AASM also recommends for habit-forming medications such as zolpidem and benzodiazepines, despite weak evidence of their benefits vs harm.

I always recommend that people optimize their vitamins, minerals and phytonutrients by eating an anti-inflammatory diet rich in vegetables and fruits. You will never regret eating for your health. And as mentioned, the common supplements on the market have variable data to support their use. More over, as mentioned in part 1, there may be an underlying condition causing your insomnia. Once again, if you are having difficulty sleeping, it is best to discuss with your healthcare provider who will make the appropriate treatment recommendations for you^.

References:

Dr. Sydne Ford, MD is a board-certified Family Medicine physician at the Emory at Acworth clinic in Georgia. She works with patients of all ages, starting as early as newborns. She is passionate about supporting women’s health, adolescent medicine, and health disparities. At the core of her work, is her desire to get to the root cause of disease and prevent, reverse, or manage chronic diseases using mind-body medicine, nutrition, and movement. She is currently pursuing further training through The Institute for Functional Medicine. She can be found on Instagram at @thehippiedoc.

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