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					     Sleep, Naturally

    Kathi J Kemper, MD, MPH,
 Caryl Guth Chair and Director
  of the Center for Integrative
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
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.
 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
       4. Friendship with others
         (nurturing relationships)
       5. Fields: Environment
Healthy Habits, Healthy Habitat

       Relationships   Food

    Manage Stress
1. Food as Medicine
1. Food: Nutrition for Sleep
     Eat well earlier in day
     Avoid:
        Big, heavy meals late
        Caffeine (guarana, watch the
        Alcohol
     Bedtime snack: Protein
      (tryptophan) + carb snack
      (milk, peanut butter and
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,
            Magnesium, Zinc)
Top Foods (scores > 90/100)
  Broccoli                             Green
  Oranges                         Tomato
  Green Beans                     Clementine
  Pineapple                        Watermelon
  Radish                          Mango
  Summer Squash                   NF Milk
  Apple                           Figs
  Grapes                          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
      Managing stress: exercise,
       sleep, nutrition,
         Meditation
         Biofeedback
         Hypnosis, guided imagery,
          inspiring stories, prayer,
          time in nature, CBT, artistic
3. Stress management:
     Meditation training ↑ left-
      sided anterior activation, a
      pattern associated with
      positive affect, in meditators
      compared with the non-
     Positive effects on sleep for
      meditation and meditative
      movement (yoga)
     Few side effects; can combine
      mindfulness with CBT
              Davidson RJ Psychosom Med, 2003
 Stress, Emotion, and
Physiological Activation
   High Arousal/High Energy

       Low Arousal/Low
                              Institute of
 Stress, Emotion, and
Physiological Activation
  High Arousal/ High Energy

        Negative                       Positive
        Emotion                    Emotion


         Low Arousal/
          Low Energy
                                  Stress, Emotion, and
                                 Physiological Activation
                                        High Arousal/High Energy
       Frustration, Anger, Hostility,                                                        Exhilaration, Passion,
               Fear, Worry Anxiety                                                           Joy, Happiness

        Judgment, Resentment,                                                                       Love, Care,
Feeling Overwhelmed, Anguish
                                              Negative                       Positive
                                              Emotion                    Emotion               Kindness, Appreciation

    Hopelessness, Submission,                                                                     Compassion, Tolerance,
         Despair, Depression                                                                       Acceptance, Forgiveness

                      Burnout, Withdrawal,                                              Serenity, Inner Balance,
                          Boredom, Apathy                                               Reflection, Contentment

                                             Low Arousal/Low
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
               McLay RN, Appl Psychophysiol Biofeedback. 2009
                                  Morgenthaler T. Sleep, 2006
Stress Management: Compassion
      Extend good will to self or
       May you be safe and
       May you be healthy and
       May you be peaceful and
       May you have good
Supportive relationships
    Don’t go to bed mad (or
     sad or worried)
    Social support protects
     mental health
    Rx: spend time with
    Volunteer – those who
     help others feel better
     about themselves; mentor,
     tutor, coach, babysit
    Join clubs, leagues,
     scouts, church
Healthy habitat: Sleep
  Bright light in early morning
  Sleeping room DARK (watch
   night lights, electric clocks,
   computer screens), cool,
  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?
    5-HTP? Valerian?
   No caffeine within 8 hours of
   Music, calm, orderly, quiet
   NO vigorous exercise right before
   GET MORE versus intentional
    sleep reduction/deprivation
   Aim for earlier; enough to awaken

 Supplements
 Massage
 Acupuncture
 Electrotherapy
 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:
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
 (
 Decreases itch, pain,
  anxiety, depression; and
  improves sleep (Field T,
  multiple years and pubs)
 Can be done by parents
 Previously provided by
 Found in many nurseries
 Licensing for
  professionals varies by

 Tiny needles, needles not
  always necessary (pressure,
  massage, laser, magnets,
 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.
(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
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;
    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
           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
          0 1 2 3 4 month?9 10
                    5 6 7 8
          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
      Identify 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/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)
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
Next steps?
 Focus on fundamentals: food (watch
  caffeine, alcohol, xs meals; bedtime
  snack?);fitness; friendship with self
  (manage stress and emotional states);
  friendship with others; healthy
 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
            More resources
 Mental Health, Naturally
   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

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