Sleeping Well (1/2)

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Improving your sleep quality is one step you can take to improve your resilience and well-being. It may possibly improve your response to treatment, also.

Sleeping Well

Improving your sleep quality is one step you can take to improve your resilience and well-being. It may possibly improve your response to treatment, also.

The Importance of Sleeping Well

Getting adequate sleep and rest is considered an essential lifestyle strategy to include in an integrative cancer care plan. Integrative cancer care specialists such as Keith Block, MD; Gary Deng, MD; Lise Alschuler, ND, FABNO; and Nasha Winters, ND, FABNO, all emphasize the importance of balancing one’s biorhythms (also called circadian rhythms) to create an internal environment that is hostile to cancer cells while also promoting healing and health. The sleep/rest/activity cycle is one of those rhythms. Dr. Deng considers sleep as one of the 6 Pillars of Good Health (the others being exercise, diet, stress management, relationships and meaning).

  • Worse survival, plus more interference with function, more anxiety and depression, poorer nighttime sleep, more daytime fatigue, and poorer quality of life among people with advanced lung cancer suffering greater circadian activity/sleep cycle disruption compared to those who maintained good circadian integration1
  • Substantially longer survival, plus better quality of life and less fatigue among people with metastatic colorectal cancer who had marked rest/activity rhythms in a mid-sized observational study2
  • Higher levels of anxiety, fatigue, and depression were linked to poorer sleep quality among adults with multiple sclerosis in a mid-sized observational study.3

Sleep (especially sleep at night) is the time when our bodies maintain optimal functioning of our immune, cellular, metabolic and endocrine (hormonal) systems. Sleep is also important for optimal cognitive functioning. For more information about the importance of sleep, see the National Heart, Lung and Blood Institute's page: Why Is Sleep Important?

Health Effects of Poor Sleep Quality

Good sleep is necessary not only for physical health, but for mental and emotional health as well. Poor sleep, or even too much sleep, is linked to many physical, mental and emotional problems:4

 

  • Weakened immunity
  • Insulin resistance
  • Inflammation
  • Impaired digestion and detoxification
  • Changes in gut bacterial balance
  • Obesity
  • Depression
  • Fatigue
  • Irritability
  • Anxiety
  • Chronic diseases including cancer
  • Cognitive impairment

 

General Health

Inadequate sleep at night leads to these physical responses:

  • Low levels of melatonin, a hormone naturally produced in the pineal gland that helps regulate sleep and wake cycles.
  • Elevated blood cortisol levels, usually low at night but often elevated in those with chronic sleep disruption.8

Chronically elevated blood cortisol and adrenaline can cause physical changes that impact health and functioning. These changes are sometimes referred to as “weathering” of the body, akin to the weathering of a flag in a consistent high wind.9

Cancer

An extensive meta-analysis did not find an overall association between ever-exposure to night-shift work and the risk of several types of cancer (breastprostateovarianpancreaticcolorectalnon-Hodgkin's lymph, and stomach cancers).10 However, some studies have concluded that rotating schedules and many years of shift work are linked to increased risk of some cancers, especially breast cancer.11

Cancer patients also report insomnia at twice the rate as the general population.12

Cortisol, Sleep and Cancer

 

Cancer incidence, progression and mortality are linked to stress and disruption of the circadian (daily) rest and activity cycle. Cortisol, our primary stress hormone, helps regulate the sleep-wake cycle. Activation of the processes that produce cortisol (the hypothalamic-pituitary-adrenal (HPA) axis) can lead to arousal and sleeplessness.13

Although the mechanisms are not fully understood, high cortisol levels and disrupted sleep-wake cycles are connected to these outcomes:14

Cortisol in excess pushes several cancer processes forward, especially metastasis. A rise in blood cortisol in response to stress or poor sleep quality can speed up tumor growth. Cortisol suppresses immunity, which is critical in mopping up malignant cells that remain after cancer treatment.15

The combination of cortisol and adrenaline increases blood glucose levels. Chronic high blood glucose episodes can be a direct or indirect mediator of the increase in tumor cell growth.16 Cortisol also increases insulin resistance and seems to stimulate the ability of some cancer cells to grow and metastasize.17

Studies have investigated cancer outcomes related to cortisol and sleep disruption:

  • Breast cancer patients who don’t have normal cortisol rhythms have less-active natural killer cells and have reduced survival compared to others.18
  • In adults with cardiovascular and cerebrovascular diseases, sleeping less than six hours a night was associated with almost triple the risk of cancer mortality compared with sleeping six or more hours a night.19

Fortunately, improving sleep can block this cascade of effects. Sleep, and especially deep sleep, inhibits the HPA axis that produces cortisol.20 Further, the “sleep hormone” melatonin promotes sleep but is also a powerful antioxidant, promotes the activation of inflammation-related genes, and has other effects on the immune response.21 Melatonin is also instrumental in eliminating cancer cells and reducing the side effects of chemotherapy.22 Promoting optimal melatonin and cortisol cycles can bring many benefits.

 

Melatonin, Light and Sleep

Melatonin is produced naturally by the pineal gland during the early hours of night, signaling and initiating the transition from wakefulness to sleep. Individuals who experience sleep difficulties may have disrupted melatonin production.

 

One factor that influences melatonin production is bright light. Such light exposure late in the evening—and especially blue-spectrum light such as from most television, computer, mobile phone and other screens—can disrupt melatonin production and delay the initiation of sleep.23 Reducing or even eliminating exposure to bright and blue-spectrum light in the evening may be part of a treatment plan for sleep disruptions such as delayed sleep-wake phase disorder.

During the day, melatonin production diminishes as our production of serotonin and cortisol increase. Bright light in the morning boosts serotonin and cortisol while also diminishing melatonin production, leading to greater wakefulness and setting the stage for the next evening's production of melatonin.

To optimize our natural melatonin cycles and benefits, research indicates that we should curb bright light in the evening and increase bright light exposure in the morning.24 Preliminary research also shows that bright light therapy in the morning can improve sleep in people with cancer.25

 

Clinical Practice Guidelines

2009 evidence-based clinical practice guidelines for integrative oncology state: “Any of the techniques, such as relaxation, meditation, and imagery, as well as autogenic training hypnosis, self-expression, and exercise, provide specific psychological and physiologic benefits, that is, decreases in stress; improvements in sleep, mood, and pain; a decrease in stress hormones; and improvement in immunity.” Evidence also supports use of Mindfulness-Based Stress Reduction (MBSR), yoga, and psychological interventions including behavioral therapies.26

Treating the Cancer

Working against cancer growth or spread, improving survival, or working with other treatments or therapies to improve their anticancer action

Your treatment and wellness outcomes can benefit from achieving more normal circadian (sleep and rest) patterns.27 See Timing of Therapies: Chronomodulation and Metronomic Dosing.

  • Dramatically longer survival—a 50 percent higher five-year survival rate— and improved response to treatment among people with metastatic colon cancer who have restful sleep between 11pm and 7am28
  • People with metastatic colon cancer with the most abnormal sleep/activity rhythms were five times more likely to die within two years after their diagnosis29
  • Chronomodulated therapy may not be as effective when sleep-rest (circadian) rhythms are disrupted by chemotherapy,. Chemotherapy-induced fatigue and weight loss—both of which are related to poor sleep quality—early in therapy may impair the benefits of chonomodulated therapy on survival and time to progression.30

Managing Side Effects and Promoting Wellness

Managing or relieving side effects or symptoms, reducing treatment toxicity, supporting quality of life or promoting general well-being

  • Disrupted sleep, which is a sign of disrupted stress hormone rhythms, seems to make side effects of chemotherapy more intense, whereas good-quality sleep and normal rhythms can minimize these side effects.31
  • Better quality life and less fatigue were seen in metastatic colorectal cancer patients with normal 24-hour rest/activity rhythms than those with altered rhythms32
  • Sleep disruption leads to increased symptoms of depression in men with prostate cancer, possibly through dysregulating the stress response.33
  • Improved function and fewer disease symptoms among people with metastatic colon cancer who have restful sleep between 11pm and 7am34
  • More severe acute pain after surgery among women who had sleep disturbance before breast cancer surgery in a mid-sized observational study35

Reducing Risk

Reducing the risk of developing cancer or the risk of recurrence

A 2014 review concluded that maintaining a regular and adequate daily amount of sleep contributes to prevention of colorectal cancer.36 A 2013 review reported that women and men chronically exposed to night-shift work have a 50 percent increased risk of developing colorectal cancer compared to day-shift workers.37  However, long sleep duration—sleeping nine or more hours per night—is also associated with an increased risk of colorectal cancer.38

The Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons recommends regular sleep after curative treatment of colon and rectal cancer.39

Interrupted sleep caused by obstructive sleep apnea is associated with a higher risk of melanomapancreatic cancer and kidney cancers, but lower risk of breastprostate or colorectal cancers.40

Optimizing Your Terrain

Creating an environment within your body that does not support cancer development, growth or spread

Blood Sugar and Insulin Resistance

According to BCCT advisors, consistently poor sleep (and even too much sleep) can lead to insulin resistance, as well as many other physical and mental health issues.41

  • CPAP use to address sleep apnea is linked to improved HbA1c, fasting glucose, and homeostatic model assessment of insulin resistance (HOMA-IR) levels across several studies.42
  • Interventions promoting sleep quality (CBT-I and sleep education) led not only to better self-reported sleep quality but also weak trends toward lower hemoglobin A1c level and fasting glucose levels43

Inflammation and Oxidation

Cytokines are proteins with a complex relationship to your immune system and sleep cycles. If your circadian rhythm is disrupted by an external change in the light-dark cycle—such as by night-shift work or staying awake late at night—your immune cells produce a heightened proinflammatory response driven in part by cytokine release..44

Chronic inflammation is linked to sleep disturbance. Cancer treatment itself causes a marked increase in inflammation which can result not only in impaired sleep, but also depressionfatigue and cognitive dysfunction. Impaired sleep can then increase inflammation. Chronic inflammation is linked to higher cancer mortality.45

In patients with metastatic colorectal cancer, higher levels of inflammatory cytokines were linked to disrupted rest/activity circadian rhythms. Higher cytokine levels were associated with poorer response to chronochemotherapy (chemotherapy timed by circadian rhythms), poorer survival, increased fatigue and loss of appetite.46

Therapies that reduce inflammation and promote more typical sleep-activity rhythms may impact cytokine release and improve outcomes.

Sleep deprivation was associated with a significant unbalance in histone activity—important for regulation of genes—as well as oxidative stress and ongoing inflammation in animal studies.47  

Your Microbiome

Lack of sleep (sleep restriction) did not influence the gut microbiome much in either humans or animals.48

Managing Insomnia

Many people in modern society now suffer from insomnia, which is marked by these symptoms:

  • Difficulty falling asleep
  • Early awakening
  • Frequent nighttime waking and inability to get back to sleep for an hour or two
  • Not feeling refreshed in the morning

Lise Alschuler, ND, FABNO, says that many factors can interfere with the quality of our sleep: “These include unresolved stress, a noisy bedroom environment, too much light in the bedroom, a bedroom that is too warm, hormonal issues such as hot flashes, too much alcohol, insufficient protein in the evening meal and side effects of medications.49

Often insomnia is related to lifestyle choices and situations that take us away from our natural rhythms and that promote inactivity:

  • Overeating, or eating foods that interfere with sleep promotion, or eating late in the evening
  • Staying up late and “screening”—looking at TV, computer and cell phone screens for long hours, especially late in the evening
  • Overwork or nighttime work
  • Chronic unmanaged stress

Neuropsychologist Michael Howard, PhD, lectures to healthcare professionals on understanding and managing sleep disorders. He advocates first determining if presenting insomnia is primary or secondary, for the causes and remedies are different:50

  • Primary insomnia is an independent sleep disorder and typically linked to thinking and worrying, two brain processes that prevent the activation system of the brain from responding to normal signals for sleep.
  • Secondary insomnia is caused by physical or psychosocial events or issues including these:
    • Shift work
    • Job loss
    • Divorce
    • Emotional problems such as depression
    • Environmental conditions such as a warm room
    • Symptoms such as hot flashes, fever or pain

Secondary insomnia is far more common; the best way to manage it is to address the condition/symptom preventing quality sleep.

Immediately resorting to sleep medications for either type of insomnia is typically not optimal, as these medications are effective less than 10 percent of the time, they compromise one or more of the sleep cycles, and they come with side effects, some serious.

Of most benefit for primary insomnia are the psychological/behavioral/cognitive therapies that change thinking patterns and reduce worrying. Dr. Howard suggests the following steps for patients to manage primary insomnia:

  • Practice good sleep hygiene (see the section on Balancing Sleep/Rest/Activity Biorhythms below).
  • If more intervention is needed, seek professional help if the following three statements apply:51
    1. The insomnia has lasted more than three weeks.
    2. It is not improving.
    3. It is interfering with your ability to function during the day.
  • Consider working with a sleep specialist—a healthcare professional, typically in the medical or psychology fields, with specialty training in sleep medicine and sleep disorders.52
  • If the sleep specialist determines that primary insomnia is the problem, consider therapies/practices that deal with the thinking/worrying:
    • Cognitive-behavioral therapy (CBT) and counseling
    • Specific relaxation and exercise practices
    • Behavioral conditioning

 

Balancing Sleep/Rest/Activity Biorhythms

One behavioral adjustment—timing of bedtime—may improve sleep duration. For example, going to bed before midnight is associated with longer sleep in ovarian cancer survivors in the first six months following treatment.53

Noted integrative cancer specialists and BCCT advisors Keith Block, MD, and Lise Alschuler, ND, FABNO, suggest further actions for balancing sleep, rest and activity and promoting restful sleep, including these:54

  • Practice good sleep hygiene:
  • Keep your bedroom dark, cool and quiet.
  • Exercise daily.
  • Maintain a regular schedule of sleep, work, physical activity, bedtime and waking.
  • Limit daytime naps to 30 minutes.
  • Avoid caffeine and excessive alcohol consumption.
  • Avoid strenuous exercise or heavy meals for several hours before bedtime.
  • Establish a regular relaxing bedtime routine.
  • Practice a calming and meditative exercise, such as yoga, in the evening.
  • Ensure adequate exposure to natural light (sunlight in the day and darkness at night)
  • Consider using herbs or dietary supplements if needed (see Natural Products above)
  • Work in partnership with your doctor to assess and monitor hormone imbalances; this may involve lab tests.55

Dr. Block offers practical suggestions for promoting beneficial circadian function through diet, through activity, and through mind-body approaches. These approaches are described in detail in an article by Dr. Block and his colleagues, Making Circadian Cancer Therapy Practical. Their guidance on what and when to eat from Table 1 of that article:56

General dietary guidelines:

  • Eat a nutrient-dense, vegetable-rich diet.
  • Maintain a low dietary fat intake; emphasize omega-3 fatty acids.
  • Reduce your dietary glycemic load, especially in the morning.
  • Optimize your potassium–sodium intake and ratio (lower salt intake).
  • Eliminate chemicals that overstimulate neuron receptors (excitotoxins) including monosodium glutamate (MSG) and aspartame.
  • Avoid depressants and stimulants such as alcohol, caffeine and nicotine.
  • Do not overeat—consume the largest meal between noon and 6:00 pm when insulin is highest.
  • Supplement with basic vitamins and minerals for stress reduction.
  • Eat meals at the same time each day during normal waking hours.

Daylight dietary guidelines:

  • Reduce or eliminate caffeine (optional) or stop early in the day.
  • Emphasize protein earlier in the day (breakfast and lunch).
  • Avoid foods containing tyramine after dinner, which increase norepinephrine release.
  • Take adaptogens—such as Siberian ginseng (eleuthero), rhodiola, ginkgo or American ginseng—purported to aid in normalization of stress reactions and improve energy; take only in the morning if your sleep is disturbed.

Nighttime dietary guidelines:

  • Emphasize complex carbohydrates.
  • Avoid overly spiced foods or other foods that cause digestive problems during sleep.
  • Avoid caffeinated beverages and other stimulant foods, such as chocolate.
  • Reduce fluid consumption after 5 pm to reduce your need to urinate at night.
  • Avoid adaptogens and other stimulant supplements including B vitamins, tyrosine, phenylalanine, glutamine, ginsengs, dehydroepiandrosteron (DHEA) and licorice in the evening.
  • Consume herbal sedative teas or supplements—lemon balm, chamomile, valerian, hops, l-theanine, mimosa bark (Cortex albizziae), lavender, passionflower.
  • Take melatonin or 5-HTP at bedtime.

 

Activity and Sleep

When you exercise or are more active can impact not only your fitness and metabolism, but your sleep and your response to cancer treatments.

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about how and when to be active to promote normal circadian (sleep-rest) function.57
58

 

General Exercise and Physical Care Guidelines

  • Get aerobic exercise early in the day.
  • Get morning and daytime sun exposure, 15 to 30 minutes.
  • Avoid exercising to exhaustion, which increases cortisol levels.
  • Tai chi and yoga have been found to improve sleep in older persons and cancer patients.
  • Discourage daytime/evening napping.
  • Avoid overwork and other very stressful activities that could disturb sleep through anxiety and catecholamine release (see Managing Stress).

Nighttime Exercise and Physical Care Guidelines

  • Bright light exposure in early evening but dim lights in last hour before bed (see the section titled "Light" on Creating a Healing Environment)
  • Enjoy a warm bath, soothing music, or other relaxing activity before bed.
  • Reduce stimulating activity before bed.
  • Avoid evening exercise.
  • Do not lie in bed after nighttime waking.
  • Reserve your bedroom for sleep and intimacy only.
  • Develop routine bedtime practices.
  • Improve your sleep environment:
    • Complete darkness
    • Relaxing pillow
    • Comfortable, cool room temperature
    • Control noise level
    • No computer/television or other screens
    • Hide or remove clocks

 

Preparing Your Mind for Sleep

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about how to prepare your mind to promote better sleep59

 

General Mind–Body Guidelines for Promoting Normal Circadian Function

 

Food and Sleep

A fatigue-reduction diet rich in fruit, vegetables, whole grains and omega-3 fatty acid-rich foods improved sleep and fatigue in women with breast cancer.60

When you eat can impact not only your digestion, absorption of nutrients and metabolism, but your sleep and your response to cancer treatments.

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about what and when to eat to promote normal circadian (sleep-rest) function.61

 

General Dietary Guidelines

  • Eat a nutrient-dense, vegetable-rich diet.
  • Maintain a low dietary fat intake; emphasize omega-3 fatty acids.
  • Reduce your dietary glycemic load, especially in the morning.
  • Optimize your potassium–sodium intake and ratio (lower salt intake).
  • Eliminate chemicals that overstimulate neuron receptors (excitotoxins) including monosodium glutamate (MSG) and aspartame.
  • Avoid depressants and stimulants such as alcohol, caffeine and nicotine.
  • Do not overeat—consume the largest meal between noon and 6:00 pm when insulin is highest.
  • Supplement with basic vitamins and minerals for stress reduction.
  • Eat meals at the same time each day during normal waking hours,

Daylight Dietary Guidelines

  • Reduce or eliminate caffeine (optional) or stop early in the day.
  • Emphasize protein earlier in the day (breakfast and lunch).
  • Avoid tyramine-containing foods after dinner, which increase norepinephrine release.
  • Take adaptogens—such as Siberian ginseng (eleuthero), rhodiolaginkgo or American ginseng—purported to aid in normalization of stress reactions and improve energy; take only in the morning if your sleep is disturbed.

Nighttime Dietary Guidelines

 

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