PaleoHikerMD

Being that I am a sleep doctor, one of the things that I found most curious about my transition to a Paleo diet is how much it seems to have improved my sleep. I was never necessarily a bad sleeper, but I find my sleep to be exceptional since my diet change. I fall asleep quickly, which I always have, but it’s the continuity of my sleep that has improved. In the past I would often toss and turn, waking up several times during the night for no particular reason. These days I fall asleep, and the next thing I know my alarm is going off and it’s morning. I feel more refreshed in the mornings and don’t feel the afternoon fatigue I used to have on occasion.

My wife has also noticed a difference. For almost two years she used Lunesta to help her fall asleep and she was tired of having to use it. It left her groggy in the mornings and she seemed to just drag all day. Without it she could not fall asleep easily so she used it out of necessity. Once she also committed 100% to a Paleo diet she began to sleep better. She got off the Lunesta and after a week or so of flushing it out of her system, she has been sleeping better than she has in over 10 years. She sleeps well, feels refreshed in the mornings, and has very infrequent awakenings throughout the night.

In almost all of my patients that have adapted their diet to the Paleolithic plan I have seen an improvement in sleep similar to our experience. So the question is why? Why does sleep, in particular sleep continuity seem to improve with a change in diet? I’ve searched the medical literature and have found no definitive studies to answer that question. So, I’m going to offer my OPINION on why this may be the case. Let’s look at a couple of things.

I discussed in a prior post that a fairly well timed hormonal dance occurs around the time we go to sleep. Cortisol nears its nadir at the time we normally fall asleep, and growth hormone is on the rise during this time. This exchange of hormone levels, along with an increase in our natural melatonin leads to us going to sleep. If these hormones are off for whatever reason, the result can be disjointed sleep. We know that cortisol and insulin are closely tied, so it makes perfect sense that by adapting a diet that lowers your overall insulin levels that will likely have a positive affect on your cortisol levels. Although maybe not completely understood, an interplay between insulin, cortisol, and growth hormone are involved in the improvements in sleep seen with Paleo.

Another area that affects sleep is your gastrointestinal system. When you eat a diet full of GI irritants, large meals are bound to affect how you feel. Your sleep is an ever changing state where you move between sleep stages freely throughout the night. Normally the changes in your sleep stages, or stage “shifts” are fairly well timed leading to a fairly small number of overall shifts though out the night. Anything that disrupts sleep such as Obstructive Sleep Apnea or Periodic Limb Movement Disorder does so by essentially increasing the number of stage shifts. This increase in shifts leads to a higher rate of arousal from sleep (aka waking up) and therefore less restful sleep. Any number of things can lead to stage shifts, including any pain or discomfort you may have. Chronic GI irritation from a traditional carb based diet leads to excessive gas, bloating, and cramping that I believe disrupts sleep quite a bit. You do not have to be completely conscious of your arousals, in fact you are not aware of most, but your brain recognizes them and you feel them in the morning as fatigue. I’m sure we all would agree that a Paleo lifestyle has led to much a much calmer GI system…to say it nicely. If we feel better in the day, we feel better at night, and we sleep better because of it as well.

Sleep is also very closely tied to one’s emotional well being. One of the most common signs of chronic depression is chronic insomnia. There are two basic forms of insomnia: sleep onset and sleep maintenance. As you may expect sleep onset insomnia is trouble falling asleep, and sleep maintenance is trouble staying asleep. A typical depressed sleep pattern is taking too long to fall asleep due to excessive thinking, and early morning awakening. This early morning awakening can be anywhere from 2-5 AM, and again is prolonged by what I call the “I can’s shut my brain off” syndrome. Once people wake up, they just can’t stop thinking enough about what they have to do or what has happened to them to fall back asleep. A gluten laden diet has been linked to depression in many studies, and many people report significant improvements in their underlying depression or hopelessness by changing to a gluten free diet. Paleo of course is gluten free and then some. It’s not hard to link a paleo diet with improved depression, and improved depression with improved sleep. When we treat depression with traditional antidepressants one of the first thing patients report is a dramatic improvement in sleep, particularly sleep maintenance. If you consider Paleo eating more of a natural antidepressant, then the improvements in sleep are easy to understand.

Lastly I think sleep is improved with the Paleo diet basically by association with other aspects of the so called Paleo “lifestyle”. When you decide to go Paleo, you normally do it with the basic intention of getting healthier and feeling better. To that end most do not stop only with their diet. Adapting a new lifestyle also includes increasing your physical activity and focusing on a more overall positive attitude. When you exercise you get tired, and getting more tired in the day leads to better sleep at night. Think of your kids; when they play hard or swim for hours they sleep like logs…we are the same!

Over the next few months, try to focus a little more on your sleep. See how certain things affect your sleep. In particular, notice how any “cheats” may affect your sleep. Some can be a little less compliant and get away with it, but many can’t. Gluten and dairy in particular can significantly affect your sleep, even in small doses.

One last thing, what if you are totally Paleo, and still can’t sleep? Paleo can make you sleep better, but it cannot treat or cure many sleep problems. Insomnia is not to be taken lightly, and can be a significant medical issue requiring sleeping pills to treat. From Restless Leg Syndrome to Delayed Sleep Phase Disorder, sleep disorders are real and are not always treatable “naturally.” Likewise, depression is a pervasive and life changing illness that often requires medication to manage. If you feel depressed despite a Paleo diet, or you can’t sleep, or both!, please do not feel “ashamed” or “weak” in any way by seeking appropriate care and treatment from a health professional. Don’t lose another night of sleep worrying about it.

-E

Around 25% of my medical practice is devoted to sleep related disorders.  Without question, the most common sleep disorder I diagnose is Obstructive Sleep Apnea (OSA) [Click HERE for a link to my guest blog article written for Dr. Samuel Bledsoe’s blog, Bariatric Freedom] Most believe insomnia would be the most common disorder, but that type of patient rarely visits my office.  Why you may ask?  Typically, because their family physician treats them with sleeping aids to band aid the problem, or they never complain because they do not recognize poor sleeping habits as a problem with a solution.

Americans do not value sleep.  I see it daily, and unfortunately I see the price my patient’s pay in their overall health.  The symptoms most commonly associated with poor sleep hygiene are daytime fatigue and poor work performance.   However, would it surprise you learn that inadequate amounts of sleep have also been linked to heart disease, high blood pressure, elevated insulin and thus blood sugar levels, worsening of asthma symptoms, and even death?  To learn why, look at one of the most common sleep problems, Obstructive Sleep Apnea.

OSA is a condition where you have intermittent pauses in breathing (apneas) while you sleep.  As you cycle through sleep, typically, you move from the lighter phases of sleep (Stages I and II) into the deeper stages (Stage III and REM).  The graph below illustrates a fairly normal sleep cycle in a healthy young adult.  I might point out that recently state III and IV sleep were combined into once stage known as Delta sleep in the sleep medical literature, and the hypnogram below still has the old nomenclature.

When you have intermittent apneas at night, usually from your airway closing on itself, it leads to at least a 10 second pause in breathing.  As your oxygen goes down, your carbon dioxide goes up.  It is this carbon dioxide that eventually reaches a level which tells your brain that it is time to breathe!  The key is when you start to breath again, you almost always experience what we call an arousal.  This means your brain waves, or EEG, shows a shift to a lighter stage of sleep, usually all the way back to wake.  Just as quickly as you woke, you fall right back asleep, but at a lighter level.  Therefore, if you have moderate sleep apnea, you may stop breathing 30 times an hour, and thus wake up 30 times an hour!  Of these, you may actually be aware of only once that you wake, but your brain is aware of each and every time.

What is the result of this very intermittent and choppy sleep?  Symptoms!  Classic symptoms of sleep apnea include feeling sleep deprived upon waking, morning headaches, drowsiness while driving, mental fogginess in the morning, fatigue, sexual dysfunction, and getting busted snoring in public places.  An analogy I tell patients is to imagine you slept 8 hours overnight; however, during this sleep period you were awakened every 30 seconds, then you immediately fell back asleep.  Obviously, you will not feel refreshed!  This is a life with sleep apnea.

It is important to note that you do NOT have to be overweight, or even snore to have sleep apnea!  Sleep apnea is caused by a narrow upper airway that has an abnormal tendency to close when relaxed.  If your airway has this propensity, you are at risk of developing OSA.  If you are at risk and gain too much weight, your chances increase dramatically.  Therefore, obesity makes OSA worse, but does not necessarily cause it.  Yes, I do diagnose 115 pound, 35 year old females with severe sleep apnea.  If you have these symptoms and they are unexplained, see a certified sleep physician.  Do not solely rely on how you feel.  Let me say that again, having sleep apnea is not necessarily related to poor life choices.  Like many disorders, you can inherit the tendency to have problems that can lead to poor health.

So, what does this have to do with anything you ask?  Let me just lay out a few of the hormonal changes that occur with sleep apnea.

-Cortisol is bad for you.  It’s bad for sleep, it’s bad for your insulin levels, and it’s bad for your blood sugars.  Cortisol normally reaches its low right before bed time, which allows for an easy transition from wake to sleep.  Sleep should be a relaxed time when your “stress-hormones”, of which cortisol is one, are at a low level.  Chronic sleep disruption from OSA leads to both, a slower level of cortisol decrease as sleep approaches, and a general increase in cortisol levels all night.  Given that cortisol increases insulin levels, which increases glucose levels and your risk for obesity and diabetes, this is clearly a problem.  This elevation in cortisol also makes controlling a diabetic’s blood sugars difficult if they have untreated OSA.

-The yin to cortisol’s yang is growth hormone (GH).  GH levels typically rise during the night as you sleep.  This is important, because GH has the ability to counteract insulin and grant you some relative protection against insulin resistance syndrome.

-Leptin is your friend.   This hormone essentially triggers to your brain that you are full.  Leptin also appears to be affected by sleep amounts!  Studies in patients subjected to sleep deprivation, in large and moderate amounts, show a significant fall in leptin levels.  This is because your bodys fat cells, which secrete leptin, are signaling to your body to eat, even when it is full! So yes, poor sleep makes you hungry.

-Grehlin, works basically the opposite of Leptin by stimulating the appetite.  If you had to guess what sleep does to Grehlin levels, what would you say?  Yep, sleep deprivation leads to abnormally high levels of Grehlin and thus hunger.

-This is just the tip of the iceberg.  The sleep medical literature is constantly finding new links to hormones and metabolism.  As things evolve, I will try to keep you informed.

So, now that I have potentially bored you all to death, what does this all mean?  OSA patients have chronic sleep disruption from the disease.  However, a result of the everyday choices we make, many of us also suffer these hormonal consequences. Think of the amount of sleep you need as a checking account.  You need to deposit a certain amount every night, in order to make withdrawals the next day.  If you fail to make nightly deposits, debt will accumulate.  Unfortunately, if you miss thirty minutes here, an hour there, and never make it up, the debt starts to accumulate fast.  After continuing this habit, your sleep debt has accumulated to such a large amount that you are bankrupt.  You are tired, cranky, sluggish at the gym, hungry, stalled on your weight loss, stressed…get the picture.  The cause of this common picture is the hormonal consequences detailed above.

WHETHER YOU HAVE SLEEP DISRUPTION FROM OSA OR CHRONIC PARTIAL SLEEP DEPRIVATION, THE CONSEQUENCES ARE THE SAME!!

The Paleo world tends to focus way too much on food, and forget about other aspects of health.  As a sleep doctor, I would sayAmerica’s overall sleep health grade is an F minus.  We don’t value sleep.  How can you want to be your best, do your best, have the best time possible without giving your body the proper rest?  It won’t work.

Like I said above, the hormonal landscape of sleep and how it affects your everyday life is a work in progress.  We just do not know everything there is about the neuroendocrine nature of sleep to connect all the dots.  However, we have connected a few important dots.

-We have mortality data demonstrating the risk of dying is 30% greater for untreated OSA at any point in your life.

-European data recently showed a significant increase in the mortality of individuals who reported sleeping less than 6 hours a night…regardless of BMI or lifestyle!

So people, no matter how “in shape” you think you are, how many pull-ups you can do, or how little carbs you eat…lack of sleep will catch up by making your long-term health worse.  Don’t get caught thinking you are above the fray because your WOD times are always best!  Get your sleep, invest in your health, you’ll be glad you did.

-E