Staying Asleep or Going to Sleep?

by Dr. Shane Steadman

One of the most common complaints among patients is sleep for a variety of reasons. They simply don’t get enough sleep, or it’s disrupted sleep. When patients say they can’t sleep or they have insomnia, the first question I ask is, “Do you have a hard time going to sleep or staying asleep?” As you are reading this article, ask this question of yourself, and then explore ways to promote sleep. The answer is usually one or the other, sometimes both. Let’s investigate the most common causes. Hint: there are similarities between the two main categories.

Difficulty Going to Sleep

Falling asleep is a frustrating aspect of sleep and can cause a lot of anxiety. Patients will talk about having anxiety after dinner knowing they can’t fall asleep. Sometimes, they lie in bed thinking about how they can’t fall asleep and eventually proving themselves correct. Others will sit in bed or watch TV until they fall asleep. These patients are essentially engaging in an activity until their system finally calms down enough to go to sleep.

Potential mechanisms to start evaluating are blood sugar and/or adrenal imbalances. The most common causes of blood sugar imbalances are associated with higher-than-normal blood sugar (fasting glucose levels above 100). The most common group to experience this is people who are insulin resistant or diabetic. However, people who are dysglycemic or have fluctuating levels of blood sugar can also experience this type of insomnia. One strategy to balance blood sugar levels is exercise and monitoring carbohydrate intake. Exercising helps with increasing the cells’ need of fuel, thereby utilizing sugars in circulation. Along with exercise, monitoring carbohydrate levels and the intake of sugar can be crucial to getting to sleep sooner. The most common sources of carbohydrate/sugar intake are ice cream, wine, chocolate or some other type of dessert. Even when people have a “little piece,” it still creates a surge of glucose, and then insulin. Additionally, abnormal surges at night and instability of glucose can impact the production of serotonin in the brain, which converts to melatonin for sleep.

In addition to blood sugar, the next area to evaluate is adrenals. Adrenals are involved in stress responses and cortisol production. Most people have experienced a stressful event, and then lie in bed trying to fall asleep. These episodes are acceptable, and everyone knows it’s temporary. However, for the person who has been under chronic stress, going to sleep can be very difficult. Chronic stress can be related to a job, family dynamics, friends, or physical stress (health issues or inflammation). Most do not understand that if the body is inflamed, an adrenal component is involved. Blood sugar instability can also cause an elevation in cortisol affecting sleep, which then leaves the person waiting for their blood sugar or cortisol to lower to allow them to fall asleep. Finally, cortisol can activate the area of the brain called the midbrain. This area of the brain is involved in the fight or flight mechanism.

To summarize, altering blood sugar levels can affect serotonin and the conversion of melatonin, both of which aid in sleep. Cortisol can increase the sympathetic stress response and activate the brain. While sleep issues are incredibly frustrating, some solutions include:

Maintain blood sugar stability throughout the day and especially into the evening.
Reduce simple carbohydrates and consume more complex carbohydrates, and include quality fats and protein in each meal.
Exercise in the form of walking can help with cortisol levels and can help with blood sugar levels.
Deep breathing and/or meditation can help calm the midbrain and reduce stress.
Reduce the amount of light stimulation at night such as computers, tablets, cellphones, and TVs. These devices can increase arousal of the brain.
Use adaptogenic herbs such as ashwagandha and holy basil for adrenal support.
Use supplements that support proper blood sugar when levels are high.
Develop a sleep routine each night.

Difficulty Staying Asleep

The other side of the coin is those individuals who have a hard time staying asleep. Often, they can fall asleep within 20 minutes, but can wake up 2-5 times a night. Some are able to fall back asleep fairly quickly, while others can be awake for an hour or two at a time. People will also talk about either waking up and lying there, or waking up and their brain will not stop. Some will even mention waking up in a cold sweat and worrying about events from the previous day or things they need to do the next day.

Again, looking at the mechanisms, two major areas need evaluation. The first is glucose and the second is adrenals. The opposite from the previous section will be discussed with these patterns, low glucose and low adrenal function. Low glucose levels are the more common patterns for blood sugar. In my office, we look at a more narrow range, which is called a functional range, as opposed to traditional ranges, but subtle changes for some individuals can have a big impact on sleep. Clinically, patients whose blood sugar levels test below 80 will describe symptoms of low blood sugar. An important item to note is that a neurotransmitter called GABA is utilized to help with inhibition (calming) of midbrain structures and limbic structures. GABA is converted from glutamate which is a byproduct of the TCA cycle involving glucose. Therefore, low levels of glucose can have an impact on GABA production. This is seen when someone becomes “hangry,” jittery, shaky, or anxious. Someone sleeping requires a level of glucose the brain needs to function and GABA to keep the brain calm and in a state of sleep. With low blood sugar, sleep can be disrupted, and individuals will wake up. Often, they will complain of waking up hungry. In a low blood sugar state, or hypoglycemia, the brain can release epinephrine via the brainstem and cause arousal and even a stress response. The effects of that are waking up and having difficulty going back to sleep.

With regards to adrenal function, it’s common to see low cortisol levels throughout the night. This can be measured using salivary testing at night. One of the many roles of the adrenal function is to support glucose during times of fasting. When looking at circadian rhythms (sleep patterns), glucose levels decrease throughout the night over time, while cortisol levels increase over time Cortisol levels remaining low can lead to a neurological response that results in arousal. Symptoms can include waking up sweating, hot, heart racing, or anxious.

Low glucose can influence an abnormal production of GABA, which is used in the midbrain and the brainstem for sleep. Low levels of cortisol or an abnormal rhythm maintained by the hippocampus can cause a loss of sleep in the middle of the night. Solutions for disrupted sleep due to poor adrenal function include:

Make sure to eat enough at dinner with good quality protein and fat, in addition to healthy carbohydrates.
If needed, consume an evening snack (i.e., ½ apple with almond butter) to support blood sugar before going to sleep.
Utilize supplements such as phosphatidylserine for support of circadian rhythms and hippocampal function.
Take adaptogenic herbs such as ashwagandha and holy basil for adrenal support.
Develop a proper sleep routine.
Maintain proper blood sugar throughout the day and do not skip meals.

There are other opinions, options, apps and techniques for sleep. Focusing on the basics and understanding how physiology works is the baseline for identifying the cause of sleep issues. Once a person has identified whether they have a hard time falling asleep or staying asleep, finding tools to help the individual will be quicker and easier.