Sleep

A summary of my thoughts about how sleep works based on my patient observation as well as current science.

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Why do we sleep?

We sleep in order to perform the daily maintenance that our body needs. The only reason why our bodies last more than a few years is because of this nightly maintenance. If we are not able to get into and stay in deep, paralyzed sleep we are not able to do nightly repair and we age more rapidly than the people around us. Most of the articles about sleep attribute our modern, widespread sleep problems to “not doing it right”; “we stay up too late, we’re too busy”. I believe that sleep is completely involuntary, normal humans can’t “do it wrong” because sleep is not really by choice. Normal healthy humans all fall asleep about the same time, 9-10pm and wake up about 6–7. Sleep has always been involuntary, since the day we were born. No matter what you want to do, you will fall asleep and you will wake up again.

Light Sleep and Deep Sleep

The first stage of sleep is Light Sleep, a “waiting phase” to be sure we “are in a safe place to get paralyzed”. Light sleep is still sleep but the brainwave pattern is irregular, and we are still moving about. After a period of time we flip into the first phase of deep sleep. There are two phases of Deep Sleep; Slow Wave Sleep and Rapid Eye Movement (REM) Sleep. The major difference between light sleep and deep sleep is that in deep sleep we are paralyzed and performing the “work” of sleep.

Repair Hormones in Slow Wave Sleep

Slow Wave Sleep is called that because the brain wave pattern becomes slow, steady and regular. As we enter this phase there begins to be a pulsatile release of Growth Hormone. This is the same hormone we use to grow as children. In kids the growth hormone is a steady flow and they grow, while paralyzed, in deep sleep. In adults this same hormone is released in pulses. I believe that this growth hormone acts as the “boss hormone” calling all the specific repair hormones; bone, muscle, tendon, joint, vein, hormones to come out as a “repair crew” to repair any injury that occurred during the day. If we move inappropriately during deep sleep the repair crew has to stop and wait, and sometimes they don’t get finished.

Why Do We Get Paralyzed?

There is a small switch in the posterior brain stem that “flips” when we enter deep sleep. This switch prevents signals from the brain from passing through the spinal cord to the face, arms and legs, paralyzing us. If you’re sleeping under a tree with your whole tribe and you talk or snore, you and your whole tribe gets found and eaten by the lions. You can also think of this paralysis as: we “turn the machine off so we can repair it”. Obviously, if we were to paralyze the chest and diaphragms we would stop breathing and die, so the switch that prevents our movement is actually designed to separate out the cells that go to the breathing muscles and allow them to keep functioning while we paralyze the rest. Also, the mouth and throat still need to move, because if we don’t swallow our own spit we’ll drown. So the paralysis “switch” in the brainstem has three groups of nerve cells; all get paralyzed, but to slightly different degrees.

What happens when we don’t get paralyzed correctly?

Two common sleep disorders seem to result from a malfunctioning paralysis switch. We can be “too paralyzed”, which results in “sleep apnea”, or “not paralyzed enough” which leads to leg movements called “Periodic Limb Movements of Sleep”. Often both happen in the same person. In order to explain this observation I picture the paralysis switch more like a speedometer needle. When it’s not working right, instead of cruise control, 55 mph, the needle is wobbling back and forth between “a little too paralyzed” and “a little not paralyzed enough”. If the mouth and throat are slightly too paralyzed, as we suck in air our throat collapses, preventing the flow of air. The brain senses that there is no air flowing and it wakes us up to light sleep. As soon as we get to light sleep we are no longer paralyzed, we open the airway again and then fall back into deep sleep. Even though this saved our life, every time we wake to light sleep and move a little, the repair crew stops working. If the normal repair phase is frequently broken up by episodes of waking to light sleep the repair cannot happen normally. Every part of the body that’s still moving or “tensed up” doesn’t get fixed and those parts may hurt when you wake up.

Rapid Eye Movement Sleep

REM sleep is the next phase of deep sleep and we are the most paralyzed in REM sleep, only the diaphragms are still moving. If a person only stops breathing in REM sleep they have “REM related apnea”. Interrupted REM sleep robs the person of the phase of sleep where we make new memories, polish old memories and probably repair the brain just like we do the body. Many people with REM related apnea not only have trouble with memory but they are also depressed or moody. This “REM related apnea” may be a milder, earlier form of the severe “sleep apnea” seen in the person who stops breathing in every stage of sleep. This is the most common pattern of abnormality in my daily headache sufferers.

Sleep Apnea Does not Just Happen to Fat People

Despite what has been written about Obstructive Sleep Apnea, most people who have this disorder are not obese and there is nothing abnormal about the way their neck is formed. They do not necessarily snore and are not always witnessed to stop breathing.

In 2009 a couple of my headache patients with sleep apnea told me that the extra vitamin D that they had started made their sleep, and then their headaches, better. This was after 6 years of wondering “why are 9/10 of the sleep studies, even in my young, healthy headache patients abnormal?” I discovered that all of my patients who had abnormal sleep also had vitamin D deficiency. I looked in the scientific literature to see if anyone had reported that low vitamin D produced sleep disorders. The answer is no, but on looking further, it turns out that there are vitamin D receptors all over the posterior brainstem, right where the “clock” that times our sleep, and the “paralysis switch” are . What if we might be able to give back something that the brain was lacking and make the sleep return to normal?

Vitamin deficiencies may cause Sleep Disorders

Vitamin D deficiency is probably the most common hormone deficiency in today’s modern world. Vitamin D used to be thought of as the calcium and bone vitamin, it is not a vitamin. Vitamin means, “my body can’t make this chemical so I need it from my environment”. It is a hormone that we make from cholesterol on our skin from the sun. D is not in the food, it’s a chemical we make. If you wanted to get enough from the milk supplementation you would have to drink 1,000 cups a day. D hormone is made from the sun to link the body’s metabolism to the length of the day. In the summer, more sun exposure and high D hormone signals the body to make more muscle, make stronger bones, and make the stomach work faster. High D signals the body to use all the food we eat to produce energy and build our body instead of storing it. We sleep less but more efficiently, so we’re up harvesting our crops or gathering food. In the winter the UVB light goes away and our D level goes lower. Low D signals the body to sleep longer, gain weight and hibernate. Hormone D is used by every organ in our body to do its job correctly. People who are D deficient are essentially in permanent winter; they get depressed, feel less active, sleep longer but don’t feel rested, they get sick more often and stay sick longer. They all sleep “wrong”. Many people are both obese and have a sleep disorder because of vitamin D deficiency.

How much vitamin D should I take to sleep well and feel better?

Over the last 30 years, as we’ve been advised to stay out of the sun, most Americans have become D hormone deficient. The FDA recommendation of 800 IU per day is way too low, but there’s a good reason for that. Having a vitamin D level that is too high is just as dangerous as one that is too low. D levels above 80 ng/ml bring back the malfunction of the sleep center and therefore all the symptoms the patient had with bad sleep and a low D, come back at with bad sleep and a high D. There’s a rather narrow band between 60–80 ng/ml where the sleep is perfect.

The FDA has been put in the unenviable position of being asked to recommend a dose of a hormone (not a vitamin) to every American. They have purposefully and wisely chosen not to try to recommend anything more than a tiny dose. This is a hormone that fluctuates in normal humans, month to month and year to year based on where you live, how much sun exposure you have and the color of your skin (which determines how fast we make D). There is no way to recommend a single, correct dose for every person. Therefore the FDA recommended dose really has nothing to do with the vitamin D dose that you should take based on your D hormone level. And the dose you need will not be the same as your relatives or your neighbors and it may change during your life depending on all of the above variables.

The only thing that is not there is the link to sleep. (Also see the vitamin D section of this site.)

D deficiency is the most common sleep disruptor but B12, B5 and iron deficiency also play a role. Most people become B12 deficient because they are D deficient. Low D make the parietal cells of the stomach produce less intrinsic factor. Intrinsic factor is a special protein that binds to the B 12 in our food to help us absorb it. Low D leads to low intrinsic factor and then to low B 12. People with known B12 deficiency should also have their D checked and replaced. If only the B12 is replaced, usually the sleep does not improve. B12 shots are not better, that belief has been disproved. Daily oral dosing of 1000mcg per day is better. We gave the B 12 shots monthly because medicare paid for it monthly, but the patients report that they need to give the shots at least weekly to see the improvement last, and if the D is given properly the stomach recovers and absorbs a daily pill without difficulty, so take the pill daily to make the sleep normal nightly.

Other neurological disorders linked to poor sleep

Each one of us has a genetic deck we’re dealt the day we are born. Each night we “shore up” each of these genetic weaknesses. I’ve learned over time that the patients with daily headaches have bad sleep, if you fix the sleep the headaches go away. Many other neurological disorders such as tremor, vertigo, epilepsy, tics, (every genetic disorder where a nerve cell is “switching on inappropriately” instead of quietly doing its job) can also be affected by bad sleep. That means a genetic disorder that’s been in your genes since the day you were born can present now and not in the first year of life because your sleep is disordered. That means it might also go away or get better when your sleep gets better. Many of those neurological disorders have been reported to be related to vitamin D deficiency: Parkinson’s disease, dementia, psychosis, depression, epilepsy, autism, ADD, gait disorders, neuropathy. The explanation for this probably resides in D’s connection to sleep.

Could my kids have sleep problems too?

Sleep disorders are not isolated to adults. Kids can be tired, listless or restless because they don’t sleep well. It is not normal for a child to have a hard time falling asleep and most of the literature telling us that “normal” teenagers “can’t” fall asleep until 1:00 am have been studying D deficient teens without realizing it. Most of our kids are D deficient (see the vitamin D section for more about this).

Sleep and Psychosis:

We all know that you can make someone “crazy” by sleep depriving them, we’ve seen it used as a form of torture on TV. People who try to sleep but can’t, can also have severe sleep deprivation. One of the things that most of us have never really thought about is how we manage to dream only while we’re sleeping. What would it be like to dream while we’re awake? Distracting at the very least, very frightening at worst. That “switch” in the brain that makes sure that dreaming only occurs during sleep is designed to be absolutely sure that we are never, ever awake and asleep at the same time. There’s a reason why we don’t want to be dreaming while we’re awake, it would produce what we call “crazy”; hearing or seeing things that aren’t really there. That means that some people who “go crazy” might have gotten there because of a sleep disorder. “Psychosis” has also been linked to both B12 and D deficiency. Post partum depression may be linked to D deficiency produced by pregnancy and worsened by accompanying B12 and other B vitamin deficiencies. If these disorders are something we could prevent by replacing a hormone deficiency I believe this should be one of medicine’s major commitments.

Other B Vitamins and Sleep

B 12 is not the only B vitamin that affects sleep. Pantothenic Acid (B5) also makes the sleep better. Importantly it appears that overdosing with the same vitamin can also interrupt the sleep, so just taking B complex without knowing the dose or the timing of supplementing can either make you much better or much worse.

It’s a little known fact that 7/8 of the B vitamins are made by our intestinal bacteria. This means that we, and all the other animals that need a daily dose of these water soluble vitamins to survive, have carried around B vitamin generator bacteria in our bodies, allowing us to survive periods as long as 2–3 weeks without eating. Because our intestinal bacteria use our vitamin D to grow normally, and because of widespread vitamin D deficiency over the last 30 years, many of us have had a change in our intestinal bacteria. Because it’s pretty hard to know what doses of the vitamins those bacteria were originally designed to supply, I think it makes the most sense to try to get the intestinal bacteria back to their normal state and let them produce the B vitamins, in addition to those that we get in our normal diet.

I realize that it’s pretty hard to know the state of your poop bacteria but, if you have irritable bowel symptoms, chronic body pain, burning in the hands and feet, balance difficulties, foot swelling, or you think, based on your medical history, that you’ve had bad sleep for over 10 years, it is likely that your poop bacteria are no longer normal. Although chronic use of antibiotics does probably affect the bacterial population in the gut I believe that is the chronic D deficiency that has brought on this change, not the common use of antibiotics. In the days before air conditioning it appears that we could safely take antibiotics for an infection and not have the big changes in sleep or health that have occurred over the last 30 years.

What do those little guys want in order to grow back?

Various authors have suggested we eat “probiotic bacteria” or even, more extreme measures such as fecal transplants (poop from one person given as an enema to another person to implant the “right” bacteria). I think that if a 3month old baby has perfect poop bacteria and we don’t feed them poop then the problem is not the supply. The bacteria in our colon apparently get in there easily, from sources all around us, they want to be in there. But if they aren’t in the right population mix throughout the gut it appears that just vitamin D replacement alone does not bring them back to their normal, healthy state. My experience has been that in order to have the “happy, helpful” bacteria grow back they appear to need the proper amount of vitamin D plus larger doses of B vitamins for about 3 months. At three to four months taking larger doses of B vitamins appears to make the sleep worse again, suggesting that the B’s are being produced normally by the intestinal bacteria and we’re adding to that with our pills. I am currently recommending to my patients that when they start D they also take B –50 ( all 8 B vitamins, 50 mg each) for three months then stop the B 50 and just continue their multivitamin. I’ve had excellent success with irritable bowel symptoms using this technique.