Sleep is a big problem. Over the last forty years our sleep has decreased to less than an average of seven hours per night per person. We live in a busy, fast paced world and in response to our ever demanding 24/7 culture our sleep is paying the price. Sleep deprivation has been associated with a number of physiological and emotional changes including imbalanced cortisol, increased ghrelin, reduced leptin, impaired glucose metabolism and increased inflammatory and pro-inflammatory markers. Even a single bad night’s sleep can adversely affect mood, concentration, alertness and insulin resistance. This all undeniably spells trouble for our cardiometabolic, endocrine and immune status especially as epidemiological observations have even concluded that sleeping less than the ‘normal’ seven hours is associated with higher all-cause mortality.
Sleep is unquestionably complex, puzzling and multifaceted but it is also a fascinating and essential biological process. Surprisingly we still have a relatively limited understanding of sleep despite ongoing research and extensive literature. Therefore, despite many health professionals’ gallant efforts to offer coaching and sleep hygiene advice, it is hardly surprising that sleep aids such as non-benzodiazepine hypnotics continue to be routinely prescribed to those with chronic insomnia, especially in the over 65 age group.
So why is sleep so important?
It is essential for cellular repair, memory processing, brain development and cognitive conditioning. It is also needed for the regulation of just about every single organ and system in the body. Without quality, restorative sleep immunity can decrease while hormone imbalances and inflammatory reactions escalate. It can also exponentially increase the risks for depression, obesity, hypertension, diabetes and dyslipidaemia.
The most common reasons for not sleeping include stress, mood disorders, hormone imbalances, urinary issues, infections, allergies, food sensitivities, inflammation, gastrointestinal problems, dysregulated blood sugar, chronic pain, circadian disruption, environmental influences, excess exposure to blue light, uncomfortable sleeping arrangements, undesirable temperatures, young children and of course snoring partners!
As a functional medicine practitioner, one of the crucial areas of questioning in any consultation is undoubtedly sleep: how long does your patient sleep; do they fall asleep easily; do they wake frequently, and do they feel refreshed in the morning? Due to the complexity of sleep, especially when it goes wrong, it is important to gather as much information as possible. At Regenerus we believe that diagnostic testing and nutritional biochemistry can significantly improve our understanding of why our patients are not sleeping. Combining this insightful data with a medical and lifestyle history can help you decipher the puzzle and allow you to efficiently and effectively support their needs.
So where do you start when it comes to testing?
Below is an overview of some of the most useful tests to help aid investigations into why our patients are not sleeping.
Comprehensive Stool Analysis
In the field of functional medicine, we all know that if you are in any doubt start with the gut and this is certainly true in relation to sleep because clinically, any unsupported gut issues, regardless of their extent, can make everything more difficult to manage and resolve. Furthermore, the intestinal microbiome produces and releases many sleep-inducing neurotransmitters such as melatonin, serotonin, dopamine and GABA that are also produced in the brain. Essentially the relationship between sleep and the microbiome is a two-way street and although our understanding is in its infancy there is growing evidence that gut health can have a huge impact on cognitive health, sleep and circadian rhythms.
Our flagship stool test is The Doctors Data Comprehensive Stool Analysis with 3 Days Parasitology (CMI04) . It is an extensive examination of the GI tract looking at gut flora, parasites, digestion, absorption, inflammation and immunology. The test evaluates the status of beneficial bacteria, imbalanced commensal bacteria, pathogenic bacteria, parasites and yeasts. If pathogenic cultures are identified, a sensitivity panel is provided to facilitate the selection of pharmaceutical or natural treatment agents. The efficiency of digestion and absorption is measured via faecal elastase, fat, carbohydrate, muscle and vegetable fibres whilst the biomarkers of calprotectin, lysozyme, lactoferrin, white blood cells and mucous can be used to assess inflammation. This can help to differentiate inflammation associated with inflammatory bowel disease (IBD) from that noted in irritable bowel syndrome (IBS). Humoral immune status of the gut is measured by secretory IgA (sIgA) while the assessment of short chain fatty acids reflects overall gut health and microbiome balance.
The DUTCH Test
The DUTCH Plus (HOR43) is a great option for assessing sleep or rather lack of sleep! This combined panel, which includes the DUTCH Complete and the DUTCH CAR (Cortisol Awakening Response), can help identify the extent of hormone imbalances in men and women. The test looks at 35 different hormone related markers; oestrogen, progesterone, testosterone, DHEA-S and cortisol along with their metabolites. It also measures daily free cortisol, the oxidative stress marker 8OHdG, melatonin, six organic acids and the Cortisol Awakening Response (CAR), which is an excellent snapshot of HPA axis function. For those with sleep issues this may not be enough so DUTCH are now proud to present the addition of the ‘Insomnia Measurement’ which also provides a cortisol measurement during the night when a patient may be struggling to sleep. So why is this test so good for assessing sleep issues? Elevated evening cortisol, low melatonin and low progesterone may all contribute to insomnia whereas vanilmandelate (VMA), a metabolite of epinephrine and norepinephrine, may be a symptom of sympathetic nervous system overdrive. Additionally, an elevated insomnia measurement can help pinpoint the role of cortisol in any sleep issues.
Neuro Biogenic Amines
Analysis of Neuro Biogenic Amines (NBA) and their metabolites provides a simple and non-invasive assessment of neurotransmitter metabolism. When functioning correctly there are natural checks and balances due to excitatory and inhibitory neurotransmitters and clinical studies have shown that inadequate or imbalanced neurotransmitter function can have a profound influence on health, wellbeing and sleep. NBAs are important regulators of the circadian rhythm and understanding their metabolism can highlight imbalances and therefore the need for any precursor amino acids or nutritional co-factors. Imbalances with histamine, glutamate or adrenaline or noradrenaline could all lead to an over stimulated brain and disrupted sleep.
Urinary NBA can be analysed via the Doctors Data Neuro-biogenic Amines Test (HOR17) or the Comprehensive Neuro-biogenic Amines Test (HOR18) . These tests provide an assessment of the ability to synthesise and metabolise neurotransmitters both in the periphery and for some enzymes, behind the blood brain barrier. In addition to the Doctors Data tests, Labrix offer an extensive menu of salivary test options that incorporate urinary neurotransmitters with the functionally interrelated adrenal and sex hormones. Due to their agonistic and antagonistic relationships this may present the most comprehensive view of any imbalances. Noteworthy tests from this rage include: Neuro Adrenal Panel (HOR14) ; Neuro Hormone Complete Panel (HOR13); Neuro Hormone Complete Plus (HOR12) and Neurotransmitter Basic (HOR11).
Thinking Outside the Box
Like eating and drinking, sleep is a vital human need. It is linked to multiple hormonal pathways and we are slowly learning more and more about its role in pathophysiology. The key to understanding sleep in clinical practice is to understand the ‘why’ of insomnia and of course there are multiple variables to consider. While the above tests are common options for sleep analysis it can prove useful to consider other factors pertinent to your patient’s case such as heavy metals, essential elements, stress or food sensitivities. As discussed, sleep is an incredibly complex subject and while diagnostic testing can help shed new light on presenting signs and symptoms, your patient’s story is always central. Reflect on the triggers and drivers of their clinical picture so you can confidently choose your diagnostic entry point.
At Regenerus we have a number of testing options relevant to sleep so if you are in any doubt or have any questions our clinical support team will be more than happy to help you select the right test for your patient.
Download this handy Sleep Hygiene Checklist from Labrix to use with your patients.