sleep, naturally
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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 - PowerPoint PPT PresentationTRANSCRIPT
Sleep, NaturallySleep, Naturally
Kathi J Kemper, MD, MPH, FAAP
Caryl Guth Chair and Director of the Center for Integrative
MedicineWake Forest University School
of MedicineWinston-Salem, NC
Kathi J Kemper, MD, MPH, FAAP
Caryl Guth Chair and Director of the Center for Integrative
MedicineWake Forest University School
of MedicineWinston-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.
ObjectivesObjectives 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
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
5 Fundamentals: Healthy Habits in a Healthy Habitat
1. Food2. Fitness3. Friendship with self
(stress and emotional self-management)
4. Friendship with others (nurturing relationships)
5. Fields: Environment
1. Food2. Fitness3. Friendship with self
(stress and emotional self-management)
4. Friendship with others (nurturing relationships)
5. Fields: Environment
Healthy Habits, Healthy Habitat
Healthy Habits, Healthy Habitat
Food
FitnessManage
Stress
Relationships
1. Food as Medicine1. Food as Medicine
1. Food: Nutrition for Sleep1. 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)
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
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)
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)Top Foods (scores > 90/100)
Broccoli Green cabbage
Oranges TomatoGreen Beans ClementinePineapple WatermelonRadish MangoSummer Squash NF MilkApple FigsGrapes Bananas
Broccoli Green cabbage
Oranges TomatoGreen Beans ClementinePineapple WatermelonRadish MangoSummer Squash NF MilkApple FigsGrapes BananasYale’s Griffin Prevention
Research Center, 2008
“Eat food. Mostly plants. Not too much.” M. Pollan. FOOD RULES
2. Fitness: Activity/Exercise2. 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
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)
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
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
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, 2003Britton WB. Psychosom Med, 2010
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, 2003Britton WB. Psychosom Med, 2010
Stress, Emotion, and Physiological Activation
High Arousal/High EnergySYMPATHETIC
PARASYMPATHETIC
Low Arousal/Low Energy
Institute of HeartMath
Stress, Emotion, and Physiological Activation
High Arousal/ High EnergySYMPATHETIC
PARASYMPATHETIC
Low Arousal/
Low Energy
Negative
Emotion
Positive
Emotion
“Fight-or-Flight”
Stress, Emotion, and Physiological Activation
High Arousal/High Energy
Low Arousal/Low Energy
Negative
Emotion
Positive
Emotion
“Fight-or-Flight”Frustration, Anger, Hostility,
Fear, Worry Anxiety
Judgment, Resentment,
Feeling Overwhelmed, Anguish
Hopelessness, Submission,
Despair, Depression
Burnout, Withdrawal,
Boredom, Apathy
Exhilaration, Passion,
Love, Care,
Joy, Happiness
Kindness, Appreciation
Compassion, Tolerance,
Acceptance, Forgiveness
Serenity, Inner Balance,
Reflection, Contentment
Stress management: biofeedback
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. 2009Morgenthaler T. Sleep, 2006
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. 2009Morgenthaler T. Sleep, 2006
Stress Management: Compassion
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
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 relationshipsSupportive 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
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
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
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 hygieneSleep hygiene
Daytime routines Exercise Light Healthy diet Good relationships
Bedtime habits
Daytime routines Exercise Light Healthy diet Good relationships
Bedtime habits
Bedtime habitsBedtime habits
Regular time; Routine Hot bath; cool, dark room; Massage before bed Lavender, chamomile, melatonin? 5-
HTP? 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
Regular time; Routine Hot bath; cool, dark room; Massage before bed Lavender, chamomile, melatonin? 5-
HTP? 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
ExtrasExtras
Supplements Massage Acupuncture Electrotherapy
Supplements Massage Acupuncture Electrotherapy
MelatoninMelatonin 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
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)
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
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-EAmino 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)
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)
MassageMassage 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
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
AcupunctureAcupuncture
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)
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
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.
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)
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
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 plansSMART Action plans
Specific, Measurable Achievable Relevant Time-specific)
Specific, Measurable Achievable Relevant Time-specific)
Pick a specific strategyPick 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
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
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)
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?
How important is this to you?
0 1 2 3 4 5 6 7 8 9 10Not 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!
0 1 2 3 4 5 6 7 8 9 10Not 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?
How confident are you that you can do this for
one month?0 1 2 3 4 5 6 7 8 9 10Not 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!
0 1 2 3 4 5 6 7 8 9 10Not 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 ConsIdentify Pros and Cons
PRO CON
Change 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/rewardsPlan 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).
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)
Sample behavior diary (OK to copy)
Goal
Sample: M T W Th Fri Sa Su Total
Walk dog 5 minutes 5 days a week √ √ √ √ √ 5
Week 1
Week 2
Week 3
Week 4
Re-evaluate.Celebrate.Next steps?
SUMMARYSUMMARY 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
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 resourcesMore 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
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