Jul
22
2017

Relaxation Reduces Inflammation

Relaxation can calm your mind, but new research has shown that relaxation reduces inflammation as well.

This article is based on a research paper in Frontiers in Immunology in June of 2017.

It concentrated on the calming effect of meditation on the nuclear factor kappa B (NF-κB), which causes inflammation. We know that overstimulation of the sympathetic nervous system activates the inflammatory pathway by expressing the genes responsible for NF-κB. These authors showed that the reverse is true also, namely that inflammation can be suppressed through meditation.

This metaanalysis of 18 research papers included 846 participants.

Here are brief summary findings of these 18 studies. Note that diverse relaxation methods had very similar results on the genes expressing inflammatory markers.

1. Qigong practitioners

A group of Qigong practitioners had 132 downregulated genes and 118 upregulated genes when compared to non-meditating controls. Meditation strengthens the immune system and delays cell death.

2. Sudarshan Kriya yoga

One form of yoga breathing is called Sudarshan Kriya yoga. When this form of breathing yoga was practiced for 1 hour per day the stress-related response on white blood cells was shielded compared to controls that did not meditate this way. Those practicing yoga had a strengthened immune system. Genes inhibiting cell death were also strengthened.

3. Chronic lymphocytic leukemia

Eight patients with chronic lymphocytic leukemia were practicing the “seven yoga breathing patterns”; the popular Indian yoga teacher, Swami Ramdev, developed these. Those patients who practiced the breathing yoga technique had 4,428 genes that were activated compared to controls. They showed an up to twofold upregulation, which strengthened their immune system.

4. Loneliness in older people

Loneliness in older people causes inflammation, morbidity and mortality. 55-85 year old volunteers were taking a course of mindfulness-based stress reduction. The researchers wanted to find out whether it was due to increased inflammation that older people were more susceptible to disease. Blood mononuclear cells were tested for genome-wide transcriptional profiling. Those older persons who had reported loneliness had more transcription factors for nuclear factor kappa B (NF-κB) than controls without feelings of loneliness. After an 8-week course those who no longer felt loneliness had a reversal of proinflammatory gene expression. The genes that had changed expression were located on monocytes and B-lymphocytes; these are cells of the immune system.

5. Care workers for patients with mental health problems

Care workers who looked after patients with mental health problems or chronic physical problems have been known to have stress-induced chronic inflammation markers in their blood. A study involving 23 caregivers used a practice of Kirtan Kriya Meditation (KKM) assisted by an audio recording every day for 8 weeks. There were questionnaires filled in for depression and mental health before and after the 8-week trial. Blood samples for transcriptional profiling were also taken before and after the KKM trial. The KKM meditation group had significantly less depressive symptoms and showed improvements in mental health. 49 genes were downregulated and 19 were upregulated compared to the controls. The pro-inflammatory NF-κB expression was decreased; the anti-viral gene expression was increased. This was measured using the IRF-1 gene. This gene controls the expression of the interferon-regulatory factor 1 (IRF-1 gene), which controls the immune response to viral infections. The interesting observation here was that a time of only 8 weeks of meditation was able to reduce inflammatory substances in the blood and could activate the immune system to fight viruses better. Further tests showed that it was the B cells and the dendritic cells that had been stimulated by the meditation.

6. Younger breast cancer patients

Younger breast cancer patients taking a mindfulness meditation course: Another study involved younger stable breast cancer patients after treatment that also had insomnia. Both breast cancer and insomnia were known to be associated with a lot of inflammatory markers in the blood. A total of 80 patients were enrolled in the study, 40 were treated with Tai-Chi exercises, the other group of 40 with cognitive-behavioral therapy. Tai-Chi exercises reduced IL-6 marginally and TNF (tumor necrosis factor) significantly. There was a 9% reduction with regard to the expression of 19 genes that were pro-inflammatory; there was also a 3.4% increase with regard to 34 genes involved in regulating the antiviral and anti-tumor activity in the Tai-Chi group when compared to the cognitive-behavioral therapy group. While cognitive therapy has its benefits, the winner was the Tai-Chi group where 68 genes were downregulated and 19 genes were upregulated. As in the prior study the pro-inflammatory NF-κB expression was decreased, which reduced the inflammatory response.

7.  Study with fatigued breast cancer patients

Another breast cancer study, this time with fatigued breast cancer patients, was observed. The patients practiced 3 months of Iyengar yoga. After 3 months of yoga there were 282 genes that were upregulated and 153 genes that were downregulated. The expression of NF-κB was significantly lowered. This suggests a lowering of inflammation. At the same time questionnaires showed that the fatigue factors had been significantly reduced 3 months after initiating yoga exercises.

8. Mindful meditation used in younger breast cancer patients

A group of 39 breast cancer patients diagnosed before the age of 50 received six weekly 2-hour sessions of mindful awareness practices (MAP). This program is tailored to cancer survivors. In addition to the group sessions the patients also did daily exercises of between 5 minutes and 20 minutes by themselves. The control group consisted of patients on a wait list. The investigators used several psychological measure (depression and stress) and physical measures (fatigue, hot flashes and pain) to assess their progress. Gene expression in the genome and inflammatory proteins were measured at baseline and after the intervention. Mindful practices showed clear benefits: they reduced stress, and sleep disturbances, hot flashes and fatigue showed improvement. Depression was also marginally reduced. There were 19 proinflammatory genes that had been turned off, but not in the control group that did not do mindful practices. Tests for changed genes revealed that transcription factor NF-κB was significantly downregulated. Conversely the anti-inflammatory glucocorticoid receptor and the interferon regulatory factors were increased. Downregulated genes were shown to come from monocytes and dendritic cells while the upregulated genes came from B lymphocytes.

9.  Telomerase gene expression

Lifestyle modification changes telomerase gene expression: 48 patients with high blood pressure were enrolled either in an extensive lifestyle program teaching them about losing weight, eating less sodium, exercising, adopting a healthy diet and drinking less alcohol; the other choice was to use transcendental meditation (TM) combined with health education with weekly sessions for 4 months. It turned out that both programs led to an increased expression of telomerase genes. Both groups did not show telomerase changes, but the authors stated that the observation time was too short for that to occur. The extensive health education program turned out to be better for patients with high blood pressure as it decreased the diastolic blood pressure more and resulted in healthier lifestyles.

10. Older patients with insomnia

Mind-body interventions for older patients with insomnia: A sample of 120 older adults with insomnia was divided into two groups. One group was treated with cognitive-behavioral therapy (CBT), the other group with Tai Chi. The control group consisted of a group of people participating in a sleep seminar. 4 months after the intervention the CBT group had a significantly reduced C-reactive protein (CRP). The proinflammatory markers were reduced in both groups after 2 months and in the Tai Chi group this remained low until 16 months. Gene expression profiling showed that CBT downregulated 347 genes and upregulated 191 genes; the Tai Chi group had downregulated 202 genes and upregulated 52 genes. The downregulated genes were mostly inflammatory genes while the upregulated genes controlled mostly interferon and antibody responses.

11. Patients with bowel disease

19 patients with irritable bowel syndrome (IBS) and 29 patients with inflammatory bowel disease (IBD) were treated with a relaxation response-based mind-body intervention. This consisted of 9 weekly meetings, each lasting 1.5 hours and practices a home for 15-20 minutes. The participants were taught breathing exercises and cognitive skills designed to help manage stress. At the end of the mind-body intervention and at a follow-up visit 3 weeks later participants of both the IBS and IBD groups scored higher in quality of life and lower in the level of anxiety they had before. They had reduced symptoms of their conditions. The IBS group showed an improvement in 1059 genes. These were mostly improvements in inflammatory responses, in cell growth, regarding proliferation, and also improvements in oxidative stress-related pathways. The IBD group showed improvements in 119 genes that were related to cell cycle regulation and DNA damages. Other genetic tests showed that NF-κB was a key molecule for both IBS and IBD. The main finding was that relaxation response-based mind-body intervention was able to down regulate inflammation in both IBD and IBS.

12. Caregivers for Alzheimer’s patients receiving a course of MBSR

A course of mindfulness based stress reduction (MBSR) was given to a group of 25 caregivers. Using 194 differently expressed genes the investigators could predict who would be a poor, moderate or good responder to the MBSR intervention. These genes related to inflammation, depression and stress response. 91 genes could identify with an accuracy of 94.7% at baseline whether the person would receive psychological benefits from the MBSR program.

13. Higher state of consciousness in two experienced Buddha meditators

Genetic test showed, similar to the other cases described here that genes involved in the immune system, cell death and the stress response were stimulated. EEG studies in both individuals during deep meditation were almost identical with an increase of theta and alpha frequency ranges.

14. Rapid gene expression in immune cells (lymphocytes) in the blood

One study used gentle yoga postures, meditation and breathing exercises. 10 participants who were recruited at a yoga camp had yoga experience between 1.5 months and 5 years. Their response resulted in 3-fold more gene changes than that of controls. Otherwise the findings were very similar to the other studies.

15. Genomic changes with the relaxation response

The relaxation response (RR) is the opposite of the stress response.  One study examined how various modes of entering into the relaxation response like yoga, Qi Gong, Tai Chi, breathing exercises, progressive muscle relaxation, meditation, and repetitive prayer would lead to beneficial gene effects. As in other studies inflammation was reduced and the immune system was stimulated from the relaxation response. This was verified with detailed gene studies. The authors noted that different genes were activated in people who had done long-term RR practice versus people who practiced RR only for a shorter time. There were distinctly different gene expressions.

16.  Energy metabolism and inflammation control

Relaxation responses beneficial for energy metabolism and inflammation control: Experts with experience in RR were compared with a group of novice RR practitioners. Experts and short-term practitioners expressed their genes differently at baseline. But after relaxation both experts and novices had gene changes in the area of energy metabolism, electron transport within the mitochondria, insulin secretion and cell aging. The upregulated genes are responsible for ATP synthase and insulin production. ATP synthase is responsible for energy production in the mitochondria and down regulates NF-κB pathway genes. Inflammation was reduced by these changes. All these beneficial gene changes were more prominent in expert RR practitioners. Other beneficial changes noted were telomere maintenance and nitric oxide production in both expert and novice RR practitioners.

17. Relaxation changes stress recovery and silences two inflammatory genes

Mindfulness meditation changes stress recovery and silences two inflammatory genes: Experienced meditators were tested after an intensive 8-h mindfulness meditation retreat workshop. Two inflammatory genes were silenced by mindfulness meditation compared to controls. Other genes that are involved in gene regulation were found to be downregulated as well. These experienced meditators had a faster cortisol recovery to social stress compared to controls.

18. Vacation and meditation effect on healing from disease

This last study investigated the effect of a 6-day holiday retreat. One group was offered a 4-day meditation course, one group was the control group just holidaying and the third group was an experienced meditation group who also took the retreat meditation course. Depression, stress, vitality, and mindfulness were measured with questionnaires. All groups were positively changed after the holiday and remained this way at 1 month after the retreat. 10 months after the retreat novice meditators were less depressed than the vacation control group. At the center of the experiment was the gene expression study. 390 genes had changed in all of the groups. The authors assumed that this was due to the relaxation experience of the retreat. The genes involved related to the stress response, wound healing, and injury. Other genes measured inflammation (control of tumor necrosis factor alpha). Another set of genes measured the control of protein synthesis of amyloid beta (Aβ) metabolism, which causes Alzheimer’s disease and dementia. All groups had markers that indicated less risk of dementia, depression and mortality, which was likely due to the relaxation from the retreat.

Relaxation Reduces Inflammation

Relaxation Reduces Inflammation

Conclusion

This study is a meta-analysis of 18 research papers. The authors found that very different approaches to relax the mind have fairly consistent universal effects on reducing inflammation. Most of this work was done with genetic markers. No matter what type of relaxation method you use, you will have beneficial effects from it. But the beneficial effect is not only strengthening the immune system, it also improves sleep, depression, anxiety and blood pressure. In addition it is improving your stress response, wound healing, risk of dementia and it reduces mortality. We don’t quite understand all of the details yet.

What is definitely documented is the effect of the mind-body interaction. It also points clearly to the relaxation response from meditation and similar relaxation methods. This has been proven beyond any doubt through genetic tests.

Dec
03
2016

Electronics In The Bedroom

There is new research showing that electronics in the bedroom can interfere with a normal sleep pattern. Dr. Ben Carter is the lead author and a senior lecturer in biostatistics at King’s College London. He just completed a study involving 125,198 children with an average age of 14½ years. There were about equal amounts of males and females. Both sexes had the same problem. When they were allowed to use electronic media, this interfered with their sleep time. What electronic devices are we talking about? Watching TV, using the computer, the cell phone, tablets and computer games. The study was originally published at JAMA Pediatrics.

Result of the study on electronics in the bedroom

  1. When media bedtime use was allowed, there was a 2.17-fold higher risk of not getting enough sleep quantity. This was compared to kids who did not use media devices in the bedroom.
  2. There was a 1.46-fold risk of having poor sleep quality.
  3. There was a 2.72-fold risk of excessive daytime sleepiness.
  4. Even children who had access to media use, but did not use it at night had similar findings. They had a risk of 1.79-fold to get inadequate sleep quantity. There was a 1.53-fold risk of poor sleep quality. And excessive daytime sleepiness was present with a 2.27-fold risk.

Melatonin level influenced by electronics in the bedroom

The diurnal hormone rhythm has been well researched regarding our sleep pattern. Essentially two hormones work together.

In the morning when you open your eyes, light enters our eyes and is registered in the hypothalamus. There are also links from the hypothalamus to the pineal gland, where melatonin is synthesized and stored. The light signal stops the secretion of melatonin from the pineal gland, although it is still being produced during the day in the pineal gland, but stored there until the evening hours set in. You may have noticed that you start yawning when the light dims in the evening. That’s when melatonin is released into your system to let you know it’s time to slow down and go to sleep.

Of course, we have electrical light and can turn night into day if we choose to! This works for a limited time, but eventually tiredness sets in, and melatonin wins the upper hand. Melatonin is the master hormone of the circadian rhythm.

It is interesting to note that cortisol does exactly the opposite. Cortisol is the adrenal gland hormone that helps us cope with stress. When we are fully awake, we need cortisol to cope with the various stress situations of the day. Melatonin inhibits cortisol secretion and cortisol inhibits melatonin secretion, and they are natural opponents working together for your common good. This is part of the circadian rhythm. We can measure these hormones, and this is how researchers have found out how these two hormones work together.

When children or adults expose themselves too much to electronic devices, the brain gets stimulated and sends signals to the adrenal glands to produce more cortisol. In between the hypothalamus and the adrenal glands there is a cascade of hormones that are involved in this.The hypothalamus sends CRH, the corticotropin-releasing hormone to the pituitary, which stimulates in turn the release of the messenger hormone ACTH to produce more cortisol in the adrenal glands. It is the extra cortisol that keeps kids awake. The same applies to adults who invite electronics into their bedroom. All the excitement from watching the various media gadgets leads to extra cortisol. And we just learnt that cortisol counteracts melatonin. 

What can parents do about electronics in the bedroom?

First of all, parents need to be firm with their kids. They need to explain to them that electronics need to be kept out of the bedroom. There needs to be a cooling down period one hour before bedtime where they do not watch TV, use the cell phone or other electronic gadgets. They may rebel against this first, but when they sleep better, they likely will be more agreeable. Here is a list that contributes to better sleep habits and better sleep quality:

  • Ensure that the bedroom is dark, soundproof, and comfortable with the room temperature being not too warm. It is important to develop a “sleep hygiene”. This means going to sleep around the same time each night, to have some down time of 1 hour or so before going to bed and get up after the average time of sleep (for most people between 7 to 9 hours). Sleeping in is not a solution, and an alarm clock will help also to develop a sleep routine.
  • Caffeine drinks, alcohol, nicotine and recreational drugs must be avoided. Smokers should butt out no later 7PM, as nicotine is a stimulant.
  • Getting into a regular exercise program, either at home or at a gym is beneficial.
  • Avoid a heavy meal late at night. A light snack including some warm milk would be OK.
  • It is not a sensible idea to use the bedroom as an office, reading place or media center. It paves the way to the stimulus of the cortisol effect that keeps us awake. The bedroom is a place of rest and should be comfortable and relaxing.
  • Some sleepers wake up at night, and they are wide-awake! Leaving the bedroom and relaxing in the living room for a while can help. It goes without saying that playing video games will not help! An alternative is to take 3 mg of melatonin, which will helps to fall asleep faster, but melatonin will wear off after about 4 hours.
  • A self-hypnosis recording is a useful adjunct to a sleep routine. Listening to it before going to sleep helps to focus on relaxation and to stop ruminating about the day and its events. Keep the volume low.

Some thoughts about sleep aids after electronics in the bedroom are removed

Sometimes an adolescent will have trouble falling asleep. Here is the solution of what to do: at the time the youngster is having problems sleeping, there is too much cortisol on board, which prevents the melatonin from being released from the pineal gland. What is missing is melatonin.

The first step is to take 3mg of melatonin at bedtime. It takes 20 to 30 minutes for melatonin to take effect. If the youth does not fall asleep within that time frame he or she is likely thinking too much. If that were the case, I would recommend taking 1 or 2 capsules of valerian root (500 mg strength) from the health food store. This combined with the melatonin should help in more than 80%-90% of insomnia cases. If the child still cannot sleep, see your physician. The adolescent may need sleep studies done or may have problems with the thyroid (hypo- or hyperthyroidism), which may need to be checked. Other medical problems, including depression, have to be checked out as well. Melatonin and valerian are safe. Other sleeping pills have multiple side effects including memory problems.

Electronics In The Bedroom

Electronics In The Bedroom

Conclusion

A new study has shown that electronics in the bedroom will often keep children awake. It has become a huge problem in schools where students fall asleep or have problems paying attention. There are simple rules regarding a quiet bedroom without electronics that will go a long way of rehabilitating a child who has sleeping problems because of electronics. There are natural ways to help nature along, if the simple measures don’t work. Melatonin and valerian root help to calm the mind and help catching some healthy sleep. If the problem were persisting, an appointment with the family physician would be in order.

Even though this article deals with children and adolescents and the use of electronics in the bedroom, the same applies to adults. They are not immune to the stressors that disrupt sleep. They are just as likely to feel tired and sluggish after a restless sleep, and their performance at the workplace will suffer. Sleep hygiene is as important for adults as it is for adolescents.

Nov
12
2016

Stress Drives Our Lives

Every year the American Psychological Association (APA) monitors the American public how stress drives our lives. This yearly report has been compiled since 2007. About 75% of the people questioned reported that they have experienced moderate to high stress over the past month.

Symptoms when stress drives our lives

What kind of symptoms can stress cause? It can cause sleep deprivation, anxiety, headaches and depression. But there can be more symptoms from any disease that stress may cause. The “Stress in America” report from February 2016 shows on page 5 that unhealthy life habits are used by low-income Americans to cope with stress. A bar graph shows that watching television or movies for more than 2 hours per day is common. Another way of coping is to surf the Internet more often, take more naps or sleep longer. Eating more, drinking alcoholic beverages and smoking more are other unhealthy ways to cope with stress.

As the stressed person gains extra weight and eventually becomes obese, there is a higher rate of diabetes that can develop with all of its complications.

Causes of stress in our lives

The “Stress in America” survey was based on 3,068 adults in the US who completed the survey during August 2015. 72% were stressed out about financial issues. 22% of these said that they were extremely stressed in the past month as a result of money concerns. Other common concerns were work, the economy, family responsibilities and concerns about personal health. Average stress levels among Americans decreased when compared to 2007. On a 10-point stress score respondents rated their stress at 4.9 in 2016 compared to 6.2 in 2007. But according to the American Psychological Association this is much higher than a stress rating of 3.7 considered to be a healthy level.

Stress affects people from all walks of life, workers, women, young adults, students and those with lower incomes.

“Stress is caused by the loss or threat of loss of the personal, social and material resources that are primary to us” Stevan Hobfoll, PhD, a clinical psychologist from Rush University Medical Center said. “So, threat to self, threat to self-esteem, threat to income, threat to employment and threat to our family or our health…” is what causes stress.

Stress drives our lives causing disease

When stress is too much for our system, we are starting to see pathology develop. “Stress is seldom the root cause of disease, but rather interacts with our genetics and our state of our bodies in ways that accelerate disease” professor Hobfoll says. The following are common diseases that can result from chronic stress.

Heart attacks and strokes

In a 2015 Lancet study 603,838 men and women who worked long hours were followed for a mean of about 8 years with respect to heart disease or strokes. All of the subjects were free of heart attacks and strokes when they entered into the study. There were a total of 13% more heart attacks in those who worked extra hours compared to those who worked 40 hours per week or less. With respect to strokes there were 33% more strokes in those who worked long hours. A dose-response association was calculated for strokes in groups with various workloads. Compared to standard working hours there were 10% additional strokes for 41-48 working hours, 27% for 49-54 working hours and 33% for 55 or more working hours per week.

Stress drives our lives and causes substance abuse

In order to cope with stress many of us treat daily stress with alcohol. It makes you feel good subjectively, but it can raise your blood pressure causing heart attacks and strokes down the road. A low dose of alcohol may be healthy, but medium and high doses are detrimental to your health.

Next many people still smoke, which has been proven long time ago to be bad for your health. It can cause heart attacks, various cancers and circulatory problems leading to leg amputations.

Overeating is another common problem. As comfort food relieves stress, extra pounds are put on. As you know it is easier to put weight on than get it off. Being overweight or being obese has its own problems: arthritis in the hips and knees makes walking more difficult. The metabolic syndrome sets in, which is a characteristic metabolic change causing diabetes, high blood pressure, heart attacks, strokes and certain cancers. The more weight you carry, the less likely you are to exercise. This deteriorates your health outlook.

Diabetes

Stress causes too much cortisol secretion from the adrenal glands. This raises blood sugar, and when chronic can cause diabetes. In addition unhealthy eating habits associated with stress can cause weight gain and high blood sugars leading to diabetes.

In a 2012 California study 148 adult Korean immigrants were examined. They all had elevated blood sugars confirming the diagnosis of type 2 diabetes. Their waist/hip ratio was elevated.

A high percentage of the study subjects had risk factors for type 2 diabetes. This included being overweight or obese and having high blood glucose readings. 66% of them said that they were feeling stressed, 51% reported feeling anxious, 38% said they were feeling restless, 30% felt nervous and 3% said they were feeling hopeless.

An Australian long-term follow-up study computed risk factors for developing type 2 diabetes. Stress was a major contributor to diabetes.

Diabetes was significantly associated with a 30-day episode of any anxiety disorder with a 1.53-fold risk. A depressive disorder had a 1.37-fold risk to cause diabetes and posttraumatic stress disorder had a risk of 1.42-fold to cause diabetes.

Infertility

Stress changes hormones in women causing ovulation problems and infertility. 1 in 8 couples in America have problems getting pregnant. Stress has been identified as being at least a contributing factor. But in men stress can also reduce sperm count and semen quality as this study describes.

Alzheimer’s disease

A 2010 study from Gothenburg University, Sweden examined 1462 woman aged 38-60 and followed them for 35 years.

Psychological stress was rated in 1968,1974 and 1980. 161 females developed dementia (105 Alzheimer’s disease, 40 vascular dementia and 16 other dementias). The risk of dementia was reported higher in those women who had frequent/constant stress in the past and was more severe the more stress they were exposed to in the past. Women who were exposed to stress on one, two or three examinations were observed to have higher dementia rates later in life, when compared to women who were not exposed to any significant stress. Specifically, dementia rates were 10% higher when exposed to one stressful episode, 73% higher after two stressful episodes and 151% higher when exposed to three stressful episodes.

Remedies for stress

Before you can attempt to remedy stress, you must first detect that you are under stress. You can recognize this when you have problems sleeping, you suffer from fatigue, when overeating or undereating is a problem, and if you feel depressed. Others may feel angry or are irritable. Some bad lifestyle habits may also make you aware that you are under stress. You may smoke or drink more in an attempt to manage stress. Some people abuse drugs.

Here are some suggestions how to remedy stress:

  1. Seek support from family, friends or religious organizations. If you engage in drugs or alcohol overuse or you feel suicidal, it is best to seek the advice from a psychiatrist or psychologist.
  2. Engage in regular exercise. This produces endorphins, the natural “feel-good” brain hormone. This reduces symptoms of depression and improves sleep quality.
  3. Do something that increases pleasure, such as having a meal with friends, starting a hobby or watching a good movie.
  4. Positive self-talk: avoid negative thoughts like “I can’t do this”. Instead say to yourself “I will do the best I can”. Psychologists have developed a technique where they teach patients how to turn negatives into positives. It is called “cognitive therapy”. You may want to seek the advice of a psychologist to have a few cognitive therapy sessions.
  5. Daily relaxation: you may want to use self-hypnosis, tai-chi exercises or meditation to reduce your stress levels.
Stress Drives Our Lives

Stress Drives Our Lives

Conclusion

Stress is very common. Diverse diseases like heart attacks, strokes, diabetes and Alzheimer’s disease can all be caused by stress. It is important to minimize the impact of stress by seeking family support and support from friends. Engaging in regular exercise will release endorphins and make you feel better. Relaxation exercises and seeking counselling can all help you to manage stress. It is not a force in your life that can be ignored or simply tolerated. Stress is indeed there, but we can make a difference by managing it to avoid that stress manages us.

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Nov
05
2016

Health Risks Of Night Shifts

One of the news stories in 2016 was about health risks of night shifts. The Bureau of Labor Statistics reported in 2000 that 15 million workers (16.8 % of the working population) were doing alternative shifts (night shift work mixed with daytime shifts). In 2016 they reported 14.8% were working alternate shifts. Among blacks, Asians and Latino Americans the percentage of working alternative shifts was higher, namely 20.8%, 15.7% and 16%, respectively.

Shift work is more common in certain industries, such as protective services like the police force, food services, health services and transportation.

Evidence of health risks of night shifts

There are several publications that showed evidence of health risks of night shift workers. Here is a random selection to illustrate the health risks of night shifts.

  1. A study from 2015 examined the sleep patterns of 315 shift nurses and health care workers in Iranian teaching hospitals. They found that 83.2% suffered from poor sleep and half of them had moderate to excessive sleepiness when they were awake.
  2. This South Korean study examined 244 male workers, aged 20 to 39 in a manufacturing plant. Blood tests from daytime workers were compared to night shift workers. Inflammatory markers like the C-reactive protein and leukocyte counts were obtained. Night shift workers had significantly higher values. The investigators concluded that shift workers have increased inflammatory markers. This is a sign of a higher risk of developing cardiovascular disease in the future.
  3. A Swedish study found that white-collar shift workers had a 2.6-fold higher mortality over a control group of daytime white-collar workers.
  4. Another study compared night workers in the age group of 45 to 54 with daytime workers and found a 1.47-fold higher mortality rate in the night shift workers.
  5. In a study from China 25,377 participants were included in a study that investigated cancer risk in males with more than 20 years of night shift work. They had a 2.03-fold increased risk to develop cancer compared to males working day shifts. Women with night shift work were unaffected with regard to cancer.
  6. A Polish study examined hormones and the body mass index (BMI) among 263 women who worked night shifts and 269 women who worked day shifts. When night shift workers had worked more than 15 years at nights, their estrogen levels, particularly in postmenopausal women were elevated compared to the daytime workers who served as controls. The BMI was also increased in the nighttime workers.
  7. Chronic lymphocytic leukemia (CLL): a study in Spain showed that working for more than 20 years in rotating night shifts was associated with a 1.77-fold higher risk of developing CLL. The authors noted that melatonin levels in that group were much lower than in controls that worked only day shifts. Working in straight night shifts did not show higher risks of CLL compared to daytime workers.
  8. In a Korean study from Seoul 100 female medical technologist who worked nighttime had their melatonin levels tested, which were compared to daytime workers.  They measured 1.84 pg/mL of melatonin for the nighttime workers compared to 4.04 pg/mL of melatonin in the daytime workers. The authors felt that this is proof that the diurnal hormone system has been disrupted. When the melatonin level is altered, the circadian hormone rhythm is also changed.
  9. A group of 168 female hospital employees doing rotating nightshift work in Southern Ontario hospitals were compared to 160 day workers. Cortisol production was assessed. Cortisol production in day workers and in shift workers on their day shift was similar. However, shift workers on their night shift had flatter cortisol curves and produced less cortisol. The authors felt that this disruption of cortisol production would explain why rotating night shift workers have a higher risk of cardiovascular diseases.
  10. A Danish study with female nurses followed 28,731 nurses between 1993 and 2015. Daytime nurses were compared to rotating nighttime nurses and the incidence of diabetes was measured. Night shift workers had a risk between 1.58-fold to 1.99-fold when compared to daytime workers to develop diabetes. The risk for evening shift workers was less (between 1.29-fold and 1.59-fold).

Diurnal hormone rhythm behind health risks of night shifts

Your body has its own rules. It rewards you, if you sleep 7 to 8 hours during the night, but it will penalize you severely, if you turn it upside down. The reason is our built-in diurnal hormone rhythm. A peak of melatonin regulates sleep during the night. Melatonin is released by the pineal gland (on the base of the skull) when it gets dark outside. Daytime wakefulness is regulated by the stress hormone cortisol from the adrenal glands. These two hormones inhibit each other, cortisol inhibits melatonin and melatonin inhibits cortisol. All the other hormones are also regulated according to the diurnal rhythm: testosterone is highest in the morning, human growth hormone is highest between midnight and 3 AM etc.

When you work daytime shifts, your diurnal hormone rhythm is unchanged. But if you work night time shifts, your hormones have to adapt. This is very similar to traveling east or west where you cross several time zones. Your internal diurnal hormone system has to adjust to these changes. Typically it takes 1 day to adjust to a 1-hour time zone difference.

In people who work permanent night shifts, the hormone changes stay adjusted and there is no further switching. But most employers want to be “fair” to everybody, so they introduced the rotating night shifts, which as all the publications cited above show is the worst thing you can do. It messes with your diurnal hormone rhythm, and some people never switch completely to the new hours worked. They don’t get enough daytime sleep because the kids are loud during the day etc. The rotating shift workers are running the highest risk of getting cancer, diabetes, cardiovascular diseases, obesity, cancer, leukemia, and they have low levels of melatonin.

Health Risks Of Night Shifts

Health Risks Of Night Shifts

Conclusion

When shift workers work constant night shifts, this is less stressful to our system than the more common rotating shift work. This is where you work night shifts for a period of time, then the schedule switches to day shift, and you keep on rotating. The least health risks are associated with regular daytime work. People exposed to rotating night shifts suffer from poor sleep. They have a higher risk of gaining weight, getting obese and acquiring diabetes in time. They are at a higher risk for heart attacks, strokes and cancer. All-cause mortality is about twofold higher than for workers who work day shifts.

The underlying problem seems to be a disturbance of the diurnal hormone rhythm. Normally this regulates our waking/sleeping rhythm and keeps us healthy. But with nighttime work melatonin production weakens, cortisol production is reduced and hormone rejuvenation during rest periods suffers greatly. This weakens the immune system, allows cancer to develop and leads to chronic inflammation causing cardiovascular disease and diabetes. The remedy to prevent this from happening is to catch little naps whenever you can during the day and, if at all possible, work daytime shifts permanently.

Sep
17
2016

Seven Steps To Live Over 100 Years

Forbes invited me to publish a blog I wrote for Quora, “Seven steps to live over 100 years”.

The topic of habits by people who live more than a hundred years has been reviewed many times in the media. It continues to be popular. Here are seven things you can do to stay healthy followed by an explanation why.

Seven steps to live over 100 years – step1: Stay active

You want to stay active every day, even if you retire. You want to move and keep your mind busy. Part of that is to do a daily formal exercise routine to keep those muscles toned, which will prevent falls in the future.

Explanation: when you keep your muscles toned and you move about, your balance organ and coordination remains sharp, you are less likely to fall and break a hip. 50% of those who sustain a hip fracture die.

Seven steps to live over 100 years – step 2: Eat a healthy diet

Eat a Mediterranean type diet or follow the Okinawan diet. These diets contain less meat (or no meat as in the Seventh Day Adventist diet), but lots of vegetables and fiber. This keeps your cholesterol down, your arteries open and your metabolism controlled, preventing diabetes. If you are not obese and you have no diabetes, you are going to be OK with your cardiovascular system for decades to come.

Explanation: Heart attacks are still on top of the mortality list. Avoid them and you got it made, if you want to make it to 100 and beyond. But we need to stay away from the poor fats and the obsession about eating beef. Red meat, if eaten too often gives you a higher risk of getting cancer and heart disease. So eat it only once a week at the most, the rest would be chicken, turkey meat or fish. Nothing wrong with a vegetarian meal, let’s say kidney beans or lentils on a day in between. This still gives you protein for your muscles, but spares you a heart attack.

Seven steps to live over 100 years – step 3: Take care of your teeth

Brush your teeth and floss every day. This will control the bacteria in your mouth and prevent leakage into your blood affecting your heart valves. Studies have shown that this prevents heart attacks.

Explanation: When I heard this first about 20 years ago, I found it strange. But the literature is clear: chronic gingivitis is associated with bacteria that grow on the gums and spread into your blood. They can then colonize your heart valves and even the lining of the arteries, particularly where there is already hardening of the arteries (arterial plaque). This can lead to heart valve disease like mitral valve disease or heart attacks.

Seven steps to live over 100 years – step 4: prevention of disease

See your physician right away if there is a new skin lesion or anything that is different on your body. Removal of early cancer and treatment of any early medical condition is always easier to treat than waiting until it is out of control. Particularly with cancer treatment at an early stage, which usually involves only a small surgical procedure, this will reward you with a ripe old age.

Explanation: I learnt this point in general practice. Patients who waited until small problems become big problems were always much worse off than patients who saw me for small problems that we could remedy at an early stage. As mentioned above this is particularly important in cancer cases, as usually stage 1 and 2 of a cancer is curable with surgery. Once you get lymph node metastases and distant metastases, the cancer is much more difficult to treat, if at all. This is a principle that is pretty much true for any disease. The prevention factor is huge. Make use of it!

Seven steps to live over 100 years – step 5: Lifestyle matters

Watch excesses like smoking (cut it out!), alcohol intake, and recreational drugs. Smoking causes heart attacks, strokes, and cancers, which shorten your life. Recreational drugs just interfere with your body chemistry and have side effects. Cut them out, if you cherish growing older than 100. Alcohol needs to be kept at a very low consumption, if you want to preserve your liver, which is your central metabolic organ. If you can’t handle moderation with alcohol consumption, cut it out. No one has died from not consuming alcohol.

Explanation: I have already explained why lifestyle choices matter. The alcohol question is one that will be discussed back and forth for centuries. There are cardiologists who tell you that men should drink 1 to 2 drinks per day and women 1 drink per day and we all live longer, because of prevention of heart disease. The wine industry makes sure that you will hear this cardiology rule. It is true that centenarians often drink one glass of red wine per day. But there are plenty of centenarians who never drank in their life. It is a matter of personal choice.

Seven steps to live over 100 years – step 6: Avoid obesity and diabetes

I did mention to avoid obesity under point 2 above, which is associated with metabolic syndrome and diabetes. Your ideal body mass index should be in the 21 to 22 range. You can achieve this by following the diets I mentioned above. You should cut out sugar and starchy foods.

Explanation: I have followed such a diet since 2001 and my body mass index is between 21 and 22. I grew up in Germany where an emphasis was put on sweets and starchy foods. Needless to say my modified Mediterranean diet deviates from the good old German diet significantly. I find healthy food very tasty.

Seven steps to live over 100 years – step 7: Sleep and hormones

Getting sleep regularly, having an optimistic outlook on life, and having good relationships help to keep the immune system strong and keep your hormones balanced. This in turn will keep you healthy emotionally and physically.

Explanation:

There are two comments I like to make. One is that when you have calm nerves, and your emotions are balanced, your stress hormones are controlled. We know that people who are laid back and easy going live longer. The type A personality is the one who gets a heart attack.

The other point is that hormones have running times. When they start missing, we get menopause or andropause. When we are in our 50’s it is time to have your hormones checked by a knowledgeable health practitioner (naturopath, anti-aging physician). At this point regular physicians are mostly uneducated about bioidentical hormone replacement. I mention this as in European studies it has been shown that replacement of missing hormones with bioidentical hormones resulted in more youthful lives. Life expectancy can be prolonged by 15 years using bioidentical hormones according to Dr. Hertoghe, an endocrinologist in Belgium. http://www.askdrray.com/life-extended-by-several-decades/

Seven Steps To Live Over 100 Years

Seven Steps To Live Over 100 Years

Conclusion

People have always been fascinated about the factors that lead to a healthy age above 100 years. I am suggesting that you concentrate on enjoying your life and keeping toxins out. Engage in some form of exercise or stay active all the time. Adopt a healthy diet. This is where perhaps most people go wrong. They think they can go on pouring junk foods and alcohol down their throats and never get heart disease or cancer. The truth is not quite like that. We do need to adopt a healthy diet like the Mediterranean diet. We also need to limit drinking to a healthy level. Replacing missing hormones with bioidentical ones will prolong your life as well. Given these recommendations, happy journey to 100 and beyond!

Jun
25
2016

Prevent Unhealthy Aging

We know that stress can age you prematurely, but what do we need to do to prevent unhealthy aging? This is exactly what this review by cardiologist Dr. Joel Kahn has done. It points out that the right lifestyle makes the difference.

Studies showing how to prevent unhealthy aging

Several studies have shown how to avoid getting heart disease, cancer and diabetes.

  1. Kahn reported that in 2001 the Harvard School of Public Health published a study where 84,941 healthy female nurses had been followed who were free of heart disease, cancer and diabetes at baseline. But only 3.4% of the 84,941 women managed to stay healthy after 16 years of the study. The secret? Their body mass index (BMI) was less than 25.0, their diet was high in polyunsaturated fat and fiber, low in trans fat and low in glycemic load, they engaged in regular moderate exercise with a minimum of 30 minutes per day; they did not smoke and they drank ½ an alcoholic drink per day. Their risk to get diabetes was 91% lower than the rest of the study. This shows you how powerful lifestyle choices are.
  2. In 2004 an international study (the INTERHEART study) reported in the Lancet the lifestyle of 15,152 cases that developed heart attacks in 52 countries with 14,820 controls who did not have heart attacks. The researchers found 9 risk factors that accounted for 90 to 95% of the heart attacks. They were smoking, elevated cholesterol risk ratio, diabetes, high blood pressure, abdominal obesity, stress, low intake of fruit and vegetables, high alcohol intake and lack of physical exercise. Obesity was considered a high risk when the waist circumference measured more than 35 inches in a woman or more than 40 inches in a man. All these 9 risks can be eliminated by lifestyle changes.
  3. The 2006 Health Professional Study spanned over 16 years in a group of 40 to 75 year old doctors without a heart attack at baseline. It noted that male doctors who were lacking the 5 heart attack risk factors had 87% less heart attacks than controls without health lifestyles. What were the lifestyle factors? A body mass index (BMI) of less than 25, being a nonsmoker, being physically active for more than 30 minutes a day, having not more than moderate amounts of alcohol intake and having a diet that was more than 40% plant based.
  4. In 2007 a Swedish study reported on 24,000 women after menopause that had no heart attacks initially. After 6 years of follow-up 308 women developed heart attacks. An analysis showed what the risk factors were for those who developed heart attacks. Those who did not have these risk factors reduced their risk of getting a heart attack by 92%. What lifestyle factors were protective? Four factors were identified: a low-risk diet (consisting of high vegetable and high fruit intake, whole grains, legumes, fish and moderate alcohol intake), not smoking, walking or biking 40 minutes daily and a low waist circumference.
  5. In 2008 the Harvard University released a study that was a further follow-up of the Health Professional study with more than 43,000 men and also the Nurses’ Health Study with more than 71,000 women. The question here was what would prevent the development of strokes? The investigators found that in both groups stroke risk could be reduced by 50% when the following 5 lifestyle factors were adhered to: no smoking, keep the BMI below 25, exercise at least 30 minutes daily with moderate activity, don’t exceed a modest alcohol intake, have a diet intake in the top 40% of fruit and vegetables and whole grains.
  6. A 14 yearlong study from the Netherlands was published in 2014, where almost 18,000 men and women without heart disease at the beginning of the study were followed. More than 600 heart attacks occurred throughout the study. People who stuck to 4 lifestyle habits reduced their heart attack rates by 67%; if they adhered to 5 lifestyle factors they reduced the heart attack rate by 83%. The 4 initial lifestyle factors were: doing an average of 30 minutes of physical activity per day, eating a Mediterranean style diet rich in fruit and vegetables and whole grains, not smoking and having more than one alcoholic drink per month. This gave you a reduced risk of your heart attack rate by 67%. Add one more good habit: sleep 7 or more hours per night on average. This reduces the risk of you getting a heart attack by 83%!
  7. A Swedish heart study with initially more than 20,000 men was going on for 11 years. There were 5 lifestyle habits the investigators identified as essential to reduce heart attack rates. Unfortunately only 1% of the study group adopted all 5 lifestyle factors, but they dropped their chance of getting a heart attack or dying of a heart attack by 86%. The lifestyle factors were: a diet rich in fruit and vegetables, legumes, nuts, whole grains and low fat; not smoking, moderate alcohol consumption, thin waistline and more than 40 minutes of physical activity.

Preserving health and vitality to prevent unhealthy aging

There is a clear pattern in all of these large studies. A healthy lifestyle preserves your health by keeping your joints and muscles in good working order. Your heart and lungs are staying well conditioned, because you engage in cardiovascular training every day. This keeps your nitric oxide going, which is an important signaling molecule that in turn reduces your blood pressure.

When we remove disabling diseases like strokes and heart attacks and prevent diabetes from developing, life expectancy is increasing. When people remain physically active even in old age, this translates into fewer disabilities and less frailty. Even Alzheimer’s disease is observed to occur less when good lifestyle habits are adhered to.

Prevent Unhealthy Aging

Prevent Unhealthy Aging

Conclusion

The studies cited here show how lifestyle factors can make a significant difference in preventing heart attacks and strokes. In the past even doctors ignored the risk of smoking. A few years back conventional medicine negated that lifestyle factors could make a difference. Now we have more studies than we need to prove that this is so. It is more important that we adhere to as many of the lifestyle factors identified in these studies to make a real difference in our lives. We also need to set an example to the next generation and to our peers. Adopting healthy lifestyle factors has to become a cultural habit for society at large. This will help reduce healthcare costs, but most importantly this will help you and me to live longer, healthier lives.

Apr
16
2016

Sleeping Habits

When you are a child or a youngster sleeping habits are rarely a problem. But as people age, they tend to have problems falling asleep and sleeping through the night. Older people may also have certain hormone deficiencies, which can contribute to a change in sleeping habits.

Some basics regarding sleeping habits

There are a couple of facts that everybody should know about sleep, so you work with nature, not against it.

  1. The way our bodies are hardwired, we need 7 to 8 hours of sleep and we need to fall asleep between 10PM and 11PM.
  2. The reason for the relative rigid sleeping schedule time wise is the diurnal hormone rhythm. This is also known as the circadian clock that is dictated by the light of the sun (24 hour cycle). Light going into our eyes in the morning inactivates melatonin. But in the evening the pineal gland releases melatonin after sunset. This is what keeps the internal clock on time. We all know how we derail when we fly east or west. There are differences. I find that I am more affected when I fly west than east. The readjustment for me often takes one or two weeks for a 9-hour time zone difference.
  3. Melatonin is gradually produced less as we age. The highest melatonin production occurs around 10 years of age. From then on melatonin production declines. This likely is the reason why older people more often have insomnia problems.
  4. There is interplay between melatonin and cortisol. These two hormones complement each other. When you sleep melatonin governs and resets the hormones to be ready in the morning. This involves an early testosterone peak for the male and cortisol, which has to be ready the moment you wake up. It is cortisol coming from the adrenal glands that rules during the day and is giving us energy. Thyroid hormones also give you energy during the day. As I will explain below, human growth hormone is an energy-giving hormone as well that also clears your mind.
  5. What is not as much known is that human growth hormone (GH) provides energy for us. Growth hormone is released as a spurt between midnight and 3 AM, when you’re deep asleep. The purpose of that is to get you ready with regard to energy for the next day. If you drink alcohol after 5PM the afternoon before, you will miss most of that GH spurt during the night and have a hangover (lack of energy the following day).  At the 23 rd Annual World Congress on Anti-Aging Medicine on Dec. 13, 2015 in Las Vegas the endocrinologist, Dr. Thierry Hertoghe from Belgium gave a talk about GH and said that even one drink during the evening before you go to sleep will cancel 75% of the GH spurt causing a lack of energy the following day. When you have alcoholic drinks evening after evening as many people do, you interfere with your deepest sleep, creating a fitful sleep and you can develop GH deficiency, which can be measured with blood and urine tests. GH deficiency leads to premature signs of aging, such as wrinkles, musculoskeletal problems, muscle weakness and dementia. Many people in their 80’s look “old”. In fact they may be growth hormone deficient and could be treated with human GH, if GH deficiency were confirmed by tests. Part of the aged appearance is reversible in cases of growth hormone deficiency by treating with daily GH injections.
  6. As we age, we produce less melatonin and less growth hormone. All of these hormone levels can be determined. If they are low, they should be replaced with small amounts of whatever hormone is missing.
  7. There are other hormones that are important for energy: cortisol from the adrenal glands, thyroid hormones and DHEA from the adrenal glands. When people get older there is a problem with melatonin production and an evening dose of melatonin supplement of 3mg is advisable. People beyond the age of menopause (females) and andropause (males) need bioidentical sex hormone replacement. Once they have sufficient hormone levels, they will also have more energy. It is advisable to get all of these hormones tested using a saliva hormone test. Growth hormone is a bit more difficult to assess, but IGF-1 levels give a first indication what your growth hormone levels are doing. The newest test is a 24-hour urine collection or an overnight urine sample looking for growth hormone metabolites. If levels are found to be low, daily replacement of growth hormone using a pen similar to insulin injections in diabetics can be given, using pure human growth hormone. You would need to seek the advice of a knowledgeable naturopath.

What does insomnia do to you?

From a psychological point of view performance is slower, there is a slower reaction time and there is a risk of developing anxiety or depression. The immune system gets weakened, high blood pressure can develop and there is a risk of developing heart disease, diabetes and cancer. It is common to gain weight becoming overweight or obese. Even your telomeres, the caps of chromosomes in every cell get shortened from too much stress and too little sleep. Shortened telomeres mean a shortened life span.

How to improve sleeping habits

Set your alarm clock for 8 hours later when you go to sleep. Make sure your bedroom is dark, but wake up to the alarm clock after 7 to 8 hours of sleep. Don’t sleep longer than 8 hours per night. Your internal diurnal hormone rhythm will thank you for regulating your sleep/wake rhythm by giving you the energy you want. I enjoy mine.

Sleeping habits include problems falling asleep or sleeping through

Falling asleep: As we mostly have a lack of melatonin, the first step is to take 3mg to 5mg of melatonin at bedtime. But it should be taken during the window of opportunity fitting into the diurnal hormone rhythm as mentioned above: between 10PM and 11PM. It takes 20 to 30 minutes for melatonin to take effect. If you do not fall asleep within that time frame, you are likely thinking too much. If that were the case, I would recommend taking 1 or 2 capsules of valerian (500 mg strength) from the health food store. This combined with melatonin should help in more than 80%-90% of insomnia cases.

Not sleeping through: Some of you, particularly if you are elderly, may wake up at 3 or 4 AM and have a hard time falling asleep again. At that time it would be safe to take another 3mg of melatonin and if this does not work within 20 minutes add another 500mg valerian capsule.

If you continue to have insomnia problems, see your physician. You may need sleep studies done or you may have problems with your thyroid gland (hypo- or hyperthyroidism), which needs to be checked. Other medical problems including depression have to be checked out as well. Melatonin and valerian are safe. Other sleeping pills have multiple side effects including memory problems.

Part of good sleeping habits is to provide a quiet, comfortable bedroom

The following points are good checklist for a comfortable sleep environment (Ref.1).

  • Ensure your bedroom is dark, soundproof, and comfortable with the room temperature being not too warm, and you develop a “sleep hygiene”. This means you get to sleep around the same time each night, have some down time 1 hour or so before going to bed and get up after your average time of sleep (for most people between 7 to 9 hours). Do not sleep in, but use an alarm clock to help you get into your sleep routine.
  • Avoid caffeine drinks, alcohol, nicotine and recreational drugs. If you must smoke, don’t smoke later than 7PM.
  • Get into a regular exercise program, either at home or at a gym.
  • Avoid a heavy meal late at night. A light snack including some warm milk would be OK.
  • Do not use your bedroom as an office, reading place or media center. This would condition you to be awake.  Reserve your bedroom use only for intimacy and sleeping.
  • If you wake up at night and you are wide awake, leave the bedroom and sit in the living room doing something until you feel tired and then return to bed.
  • A self-hypnosis recording is a useful adjunct to a sleep routine. Listen to it when you go to bed to give you something to focus on (low volume) and you will find it easier to stop thinking.
Sleeping Habits

Sleeping Habits

Conclusion

We need to be aware how important a proper hormone balance is when it comes to a healthy sleep pattern. Thyroid hormones and sex hormones are easy to measure. Bioidentical hormone replacement is needed, if one of the hormones is low. GH needs to be checked by an IGF-1 level and/or metabolites of GH in a 24-hour urine sample as explained above. Melatonin deficiency in older age is replaced the way I summarized above. With these measures sleeping habits improve, and you will get your 7 to 8 hours of restoring sleep. Forget the notion of the past that older people would not need as much sleep. Especially for an aging individual it is important to have a good night’s sleep in order to feel well and energized every day.

References

Ref.1: Jean Gray, editor: “Therapeutic choices”, 5th edition, Chapter 8 by Jonathan A.E. Fleming, MB, FRCPC: Insomnia, © 2008, Canadian Pharmacists Association.