Sleep, Naturally Kathi J Kemper, MD, MPH, FAAP Caryl Guth Chair and Director of the Center for Integrative Medicine Wake Forest University School of Medicine Winston-Salem, NC.
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Sleep, Naturally Kathi J Kemper, MD, MPH, FAAP Caryl Guth Chair and Director of the Center for Integrative Medicine Wake Forest University School of Medicine Winston-Salem, NC Faculty Disclosure Information In the past 12 months, I have had the following financial relationships with the manufacturer of commercial product(s) and/or provider(s) of commercial service(s) discussed in this CME activity: Author of Mental Health, Naturally, published by the AAP in 2010. The presentation will include no description of any proprietary items for screening, diagnosis, or treatment. I do not intent to discuss an unapproved/investigative use of a commercial product/device in my presentation. Objectives By the end of this presentation, you will be able to Identify the fundamentals for healthy sleep Describe the evidence regarding safety and effectiveness of dietary supplements, melatonin, massage, and acupuncture Use evidence-based resources to counsel patients to make optimal behavior changes to improve sleep 5 Fundamentals: Healthy Habits in a Healthy Habitat 1. Food 2. Fitness 3. Friendship with self (stress and emotional selfmanagement) 4. Friendship with others (nurturing relationships) 5. Fields: Environment Healthy Habits, Healthy Habitat Relationships Manage Stress Food Fitness 1. Food as Medicine 1. Food: Nutrition for Sleep Eat well earlier in day Avoid: Big, heavy meals late Caffeine (guarana, watch the chocolate) Alcohol Bedtime snack: Protein (tryptophan) + carb snack (milk, peanut butter and crackers) 1. Food: essential nutrients for optimal brain function Omega-3 fatty acids Amino acids (SAM-E, Trp, 5-HTP) Vitamins (B vitamins, Vitamin D) Minerals (Iron, Calcium, Magnesium, Zinc) Top Foods (scores > 90/100) Broccoli Oranges Green Beans Pineapple Radish Summer Squash Apple Grapes Green cabbage Tomato Clementine Watermelon Mango NF Milk Figs Bananas Yale’s Griffin Prevention Research Center, 2008 “Eat food. Mostly plants. Not too much.” M. Pollan. FOOD RULES 2. Fitness: Activity/Exercise 30 -60 minutes of vigorous exercise earlier in day NO vigorous exercise within 2 hours of bed Gentle stretching, yoga, Tai Chi is OK 3. Friendship with self (manage stress and emotions) Stress is common Stress makes it hard to sleep Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit Meditation Biofeedback Hypnosis, guided imagery, inspiring stories, prayer, time in nature, CBT, artistic endeavors 3. Stress management: Meditation Meditation training ↑ left-sided anterior activation, a pattern associated with positive affect, in meditators compared with the non-meditators Positive effects on sleep for meditation and meditative movement (yoga) Few side effects; can combine mindfulness with CBT Davidson RJ Psychosom Med, 2003 Britton WB. Psychosom Med, 2010 Stress, Emotion, and Physiological Activation High Arousal/High Energy SYMPATHETIC Low Arousal/Low Energy PARASYMPATHETIC Institute of HeartMath Stress, Emotion, and Physiological Activation High Arousal/ High Energy SYMPATHETIC “Fight-or-Flight” Negative Positive Emotion Emotion PARASYMPATHETIC Low Arousal/ Low Energy Stress, Emotion, and Physiological Activation High Arousal/High Energy “Fight-or-Flight” Frustration, Anger, Hostility, Exhilaration, Passion, Joy, Happiness Fear, Worry Anxiety Judgment, Resentment, Feeling Overwhelmed, Anguish Love, Care, Negative Positive Emotion Emotion Hopelessness, Submission, Despair, Depression Kindness, Appreciation Compassion, Tolerance, Acceptance, Forgiveness Burnout, Withdrawal, Serenity, Inner Balance, Boredom, Apathy Reflection, Contentment Low Arousal/Low Energy Stress management: biofeedback HRV biofeedback: useful adjunct for anxiety, depression, pain – all adversely affect sleep “biofeedback and paradoxical intention are individually effective therapies in the treatment of chronic insomnia “Board of Directors of the American Academy of Sleep Medicine Significant improvements in sleep, even in combat McLay RN, Appl Psychophysiol Biofeedback. 2009 Morgenthaler T. Sleep, 2006 Stress Management: Compassion Extend good will to self or another: May you be safe and secure May you be healthy and comfortable May you be peaceful and content May you have good friends May life go easily for you Supportive relationships Don’t go to bed mad (or sad or worried) Social support protects mental health Rx: spend time with friends Volunteer – those who help others feel better about themselves; mentor, tutor, coach, babysit Join clubs, leagues, scouts, church Healthy habitat: Sleep environment Bright light in early morning Sleeping room DARK (watch night lights, electric clocks, computer screens), cool, comfortable Turn off TV an hour before bed Quiet, white noise, or relaxing, soothing (NOT dance along or sing along) music Sleep hygiene Daytime routines Exercise Light Healthy diet Good relationships Bedtime habits Bedtime habits Regular time; Routine Hot bath; cool, dark room; Massage before bed Lavender, chamomile, melatonin? 5HTP? Valerian? No caffeine within 8 hours of bedtime Music, calm, orderly, quiet NO TV IN BEDROOM NO vigorous exercise right before bed GET MORE versus intentional sleep reduction/deprivation Aim for earlier; enough to awaken refreshed Extras Supplements Massage Acupuncture Electrotherapy Melatonin Hormone, not herb Helpful for sleep onset insomnia in ADHD (Bendz, LM. Ann Pharmacother, 2010) Can use for sleep EEG or brainstem audiometry (Ashrafi MR, Eur J Paediatr Neurol, 2010; Schmidt CM. Neuropediatrics, 2007) Dose: 0.3 – 3mg 1-2 hours before bed Products: ConsumerLab.com Sedative herbs: valerian, chamomile, hops, lemon balm, passion flower) Valerian: yes 400 mg; smells bad, but works (Morin CM, Sleep, 2005; Koetter U. Phytother Res, 2007; Bent S. Am J Med, 2006) Chamomile tea; little data, generally safe, allergies possible Hops: sleep pillow and teas; sometimes combined with valerian Lemon balm; tea Passionflower: tea Meolie AL. J Clin Sleep Med, 2005 Amino Acids: TRYP, SAM-E Acute tryptophan depletion leads to depression Dietary L-tryp -> 5-HTP -> serotonin -> melatonin Meta-analysis: 5-HTP and L-tryp better than placebo for depression (Shaw K, Cochrane. 2002) DB Xover trial in infants; cereal supplemented with 225 mgtryp improved sleep Food sources – dairy, eggs, poultry, soy, nuts; WHEY Cubero J. Nutr Neurosci, 2009 SAM-E Produced from ATP and methionine Meta-analysis: SAMe significantly improves depression, comparable to antidepressant medications ; effects on SLEEP are indirect via mood (http://www.ahrq.gov/clinic/epcsums/samesum.htm) Massage Decreases itch, pain, anxiety, depression; and improves sleep (Field T, multiple years and pubs) Can be done by parents Previously provided by nurses Found in many nurseries Licensing for professionals varies by state Acupuncture Tiny needles, needles not always necessary (pressure, massage, laser, magnets, cupping) Acceptable for kids with proper demo (model on parents ) Meta-analysis of 46 trials: significant benefit (Cao H. JACM, 2009) 2009 meta-analysis Acupuncture 46 RCTs with 3811 patients Meta-analyses showed a beneficial effect of acup compared with no treatment (p = 0.02; 4 trials) and real compared with sham acup(p = 0.04; 2 trials) on Pittsburgh Sleep Quality Index. Acup superior to medications for total sleep duration increased for >3 hours (p < 0.0001). Acupuncture plus medications better than med alone on total sleep duration (p < 0.0001). Acup + herbs better than herbs alone (p = 0.01). There were no serious adverse effects related to acupuncture treatment in these trials. Electrosleep (Cranio-electrotherapy stimulation) TENS-like device applied to earlobes or occiput bilaterally Invented in USSR 1949 Most studies in Russia and France Can help with insomnia, even anxiety, depression or those going thru drug withdrawal (Philip P. Biol Psych, 1991; Gomez E, Br J Psychiatry, 1979;Templer DI. Can Psychiatry Assoc J, 1975; Carwright RD. J Nerv Ment Dis, 1975) No RCTs in children No serious adverse effects reported SMART Action plans Specific, Measurable Achievable Relevant Time-specific) Pick a specific strategy More exercise early in day Better nutrition Judicious use of supplements Healthier environment Stress management; biofeedback; journal; meditation Massage, psychotherapy, acupuncture or other professional help Identify a small, achievable step Rome was not built in a day; habits are not changed overnight: BABY STEPS. For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week. Be specific (with or without an MP3 player; with or without a friend; regardless of weather?; distance vs. time) How important is this to you? 0 1 2 3 4 5 6 7 8 9 10 Not Very Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5) Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it! How confident are you that you can do this for one month? 0 1 2 3 4 5 6 7 8 9 10 Not Very If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and planning rewards and follow-up. If they pick a number less than 8, “What would it take for you to go from the number you picked to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent about change! Identify Pros and Cons Change PRO CON More cheerful Change routine More fit and cool Brother might tease Clothes fit better Yucky dog clean up Better sleep No Change Easy Continued mood probs Mom does yucky job Get fat Feel ugly Sleep badly Unhappy with myself Plan celebrations/rewards Pick a tangible reward and timing (will it be offered after week 1, 2, 3, 4?) Samples: new walking shoes; stickers; choice of movie. Support the patient’s choices. Emphasize the importance of the reward/celebration. If the patient says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it). Sample behavior diary (OK to copy) Goal Sample: M Walk dog 5 minutes 5 days a week √ Week 1 Week 2 Week 3 Week 4 Re-evaluate. Celebrate. Next steps? T W Th √ √ Fri Sa √ √ Su Total 5 SUMMARY Focus on fundamentals: food (watch caffeine, alcohol, xs meals; bedtime snack?);fitness; friendship with self (manage stress and emotional states); friendship with others; healthy environment Routines at bedtime; no TV in bedroom Supplements: melatonin, valerian/hops; lavender aromas; chamomile, lemon balm tea Massage, acupuncture, electrosleep Make a SMART plan consistent with family values and goals; follow-up More resources Mental Health, Naturally www.wfubmc.edu/cim Action Plan Trackers for Change･ Pros and Cons of Change Worksheet･ Action Plan Tracker for Successful Change for One Week･ Action Plan Tracker for Successful Change for Four Weeks Action Plan Tracker for Several Changes