Sleep disorder

Glaucoma: Sleep Apnea May Raise Risk.

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Patients with sleep apnea were 1.67 times more likely to develop glaucoma than patients without apnea, according to a study that compared more than 1000 apnea patients with more than 6000 age-matched participants. The study was published in the August issue of Ophthalmology.

Ching-Chun Lin, MA, from the Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taiwan, and colleagues relied on data from the Taiwan Longitudinal Health Insurance Database 2000, matching 1012 apnea patients aged 40 years and older with 6072 control patients of similar age, sex, and urbanization. A patient was considered to have apnea only if there were a record of him or her undergoing a sleep study. The researchers counted a glaucoma diagnosis only if the patient were prescribed medication.

“The fact that the authors required this [evidence of diagnosis] really increases the validity of their results,” Ahmad A. Aref, MD, assistant professor of ophthalmology, University of Illinois Eye and Ear Infirmary, Chicago, told Medscape Medical News. Dr. Aref, who authored a review on glaucoma and sleep earlier this year was not involved in the current study.

“Armed now with this study, clinicians should start to question their patients about sleep apnea,” Dr. Aref said. “I would treat it like other established risk factors for glaucoma, such as having a family member with glaucoma, or having high eye pressure, or being of African-American race. I would start to think seriously about grouping sleep apnea with those more established risk factors.”

Lin and colleagues found that the incidence rate of open-angle glaucoma among patients diagnosed with apnea was 11.26 per 1000 person years (95% confidence interval [CI], 8.61 – 14.49) compared with 6.76 per 1000 person years (95% CI, 5.80 – 7.83) for patients without an obstructive sleep apnea (OSA) diagnosis.

The adjusted hazard ratio (HR) for a glaucoma diagnosis within 5 years of being diagnosed with apnea was 1.67 (95% CI, 1.30 – 2.17; P < .001) after adjusting for monthly income, geographic region, diabetes, hypertension, heart disease, obesity, hyperlipidemia, renal disease, hypothyroidism, and number of outpatient visits for ophthalmologic care.

The adjusted HR for a glaucoma diagnosis among women in the 5 years after a sleep apnea diagnosis was 1.55 (95% CI, 1.04 – 2.31). For men, the adjusted HR was 1.45 (95% CI, 1.02 – 2.16).

“This study gives the most evidence to date that sleep apnea is a risk factor for OAG,” Parag Gokhale, MD, from Virginia Mason Medical Center, Seattle, Washington, told Medscape Medical News in an email. Dr. Gokhale, the spokesman for the American Academy of Ophthalmology, was not involved in the current research. Among the study’s strengths, he said, was the researchers’ decision to control for other possible causes of glaucoma, something several previous studies failed to do.

In this study, participants in the OSA group had higher levels of hypertension (P < .001), diabetes (P < .001), heart disease (P < .001), hyperlipidemia (P < .001), obesity (P < .001), renal disease (P < .001), and migraine (P < .001), the researchers found. Prevalence of hypothyroidism was equal in each group.

W. Christopher Winter, MD, medical director, Martha Jefferson Hospital Sleep Medicine Center, Charlottesville, Virginia, says this study should influence sleep specialists to include eye health in the list of concerns for apnea patients.

“With the risk [for glaucoma] 3 to 5 years out as high as it is, recommending a baseline eye exam would be a good thing. Eye exams, if your vision is good, usually fall by the wayside. I think I would add that,” Dr. Winter said.

The authors noted several limitations to the current study including a lack of severity information, such as apnea-hypopnea index scores or respiratory disturbance index scores, which would have allowed them to determine whether risk for glaucoma increased with the severity of the sleep apnea.

Source: Ophthalmology

 

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,”san�9rf0� ��� east-font-family:”Times New Roman”; color:black’> ABCG2 (p<0.01), the group writes. In the 134 patients on atorvastatin, explainable blood-level variability was split between two polymorphisms in SLCO1B1 (p<0.01 and p<0.05, respectively) and the activity of cytochrome P3A (CYP3A). The analyses were adjusted for gender, age, body mass index, ethnicity, statin dose, and time from last dose, and echo a 2008 study which concluded that two SLCO1B1 variants were associated with simvastatin-related myopathy, as reported by heartwire . The screening concept is currently being applied to simvastatin therapy at least at one major center.

 

The group retrospectively tested their ideas, looking at the relationships between genotypic and clinical variables and statin dose, in a validation cohort of 579 patients taking either drug in a primary care setting in the US and at a referral clinic in Canada.

The group found that the transporter genotypes that raise statin concentrations were homogeneously distributed among patients taking a range of atorvastatin and rosuvastatin dosages. That is, the prescribing physicians, armed primarily with their clinical judgment to decide dosage levels, failed to achieve optimal dosing with respect to serum drug levels. But it seemed to be only patients receiving the highest dosages who showed higher-than-safe serum levels according to genotype- and age-based criteria.

“Although we didn’t quite get to the sample size we needed, it did seem like people with the wrong genetic makeup are more likely to stop a statin or switch to [another dyslipidemia drug],” Kim said, at least among patients on the highest statin dosages.

The group’s proposed management algorithm recommends a maximum statin dosage that will result in plasma concentrations below the 90th percentile (reflecting an assumption that 10% of patients will have statin-related muscle issues) based on patient age and transporter-related genotype.

The algorithm is based on data predominantly from whites; the group cautions that some other ethnicities, “particularly Asians,” have increased sensitivity to statins.

Source: medscape.com

 

Tips for Resetting Your Internal Clock and Sleeping Better.

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Story at-a-glance

  • Factors contributing to poor sleep include vitamin and mineral deficiencies
  • Magnesium deficiency can cause insomnia; lack of potassium can lead to difficulty staying asleep; and vitamin D deficiency has been linked to excessive daytime sleepiness
  • Melatonin is one of the most important nutrients to help you optimize your sleep, as it plays a crucial role in your circadian rhythm or internal clock
  • Camping could help you reset an internal clock gone haywire from modern living, as the sun adjusts your clock to its natural state, undoing the influence of light bulbs
  • To promote good sleep, make sure you’re exposed to full natural light during the day, and avoid artificial lighting once the sun goes down, especially as bedtime draws near.
  • vitamins-sleep

Good sleep is one of the cornerstones of health, without which optimal health will remain elusive. Impaired sleep can increase your risk of a wide variety of diseases and disorders, including:

Numerous factors can contribute to poor sleep, including vitamin and mineral deficiencies. The featured article by LiveScience1 highlights three nutrients tied to three common sleep problems. To this, I would add melatonin, which is both a hormone and an antioxidant:

  • Magnesium deficiency can cause insomnia
  • Lack of potassium can lead to difficulty staying asleep throughout the night
  • Vitamin D deficiency has been linked to excessive daytime sleepiness

The Importance of Melatonin

I personally believe that melatonin is one of the most important nutrients to help you optimize your sleep, as it plays a crucial role in your circadian rhythm or internal clock.

Melatonin is produced by a pea-sized gland in the middle of your brain called the pineal gland. When your circadian rhythms are disrupted, your body produces less melatonin, which reduces your ability to fight cancer.

Melatonin actually helps suppress free radicals that can lead to cancer. (This is why tumors grow faster when you sleep poorly.) It also produces a number of health benefits related to your immune system.

For most people, the pineal gland is totally inactive during the day. But, at night, when  you are exposed to darkness, your pineal gland   begins producing melatonin to be released into your blood.

Melatonin makes you feel sleepy, and in a normal night’s sleep, your melatonin levels stay elevated for about 12 hours (usually between 9 pm and 9 am). Then, as the sun rises and your day begins, your pineal gland reduces your production of melatonin.

The levels in your blood decrease until they’re hardly measurable at all. This rise and fall of your melatonin levels are part and parcel of your internal clock that dictates when you’re sleepy and when you feel fully awake.

How to Optimize Your Melatonin and Reset Your Circadian Rhythm

In related news, research2 suggests camping could help you reset an internal clock gone haywire from modern living. As reported by the Christian Science Monitor3:

“Scientists at the University of Colorado Boulder found that if you live by the sun’s schedule, you are more likely to go to bed at least an hour earlier, wake up an hour earlier, and be less groggy, because your internal clock and external reality are more in sync. The sun adjusts your clock to what may be its natural state, undoing the influence of light bulbs. “

Since humans evolved in the glow of firelight, the yellow, orange and red wavelengths don’t suppress melatonin production the way white and blue wavelengths do. If you want to protect your melatonin cycle, when the sun goes down you would shift to a low wattage bulb with yellow, orange, or red light.

One good option is using a salt lamp illuminated by a 5-watt bulb. It’s important to realize that turning on a light in the middle of the night, even for a short moment, such as when you get up to go to the bathroom, will disrupt yourmelatonin production and interfere with your sleep.

Ideally it is best to increase melatonin levels naturally with exposure to bright sunlight in the daytime (along with full spectrum fluorescent bulbs in the winter) and absolute complete darkness at night. If that isn’t possible, you may want to consider a melatonin supplement.

In scientific studies, melatonin has been shown to help people fall asleep faster and stay asleep, experience less restlessness, and prevent daytime fatigue. Keep in mind that only a very small dose is required — typically 0.25mg or 0.5mg to start with, and you can adjust it up from there.

Taking higher doses, such as 3 mg, can sometimes make you more wakeful instead of sleepier, so adjust your dose carefully. While melatonin is most commonly used in tablet or spray form, certain foods also contain it. Cherries, for instance, are a natural source of melatonin, and drinking tart cherry juice has been found to be beneficial in improving sleep duration and quality4.

Up to 80 Percent of Americans are Magnesium-Deficient

Lack of magnesium may play a role in insomnia, and dietary surveys suggest that the majority of Americans are simply not getting enough magnesium from their diet alone5. Other factors that can make you more prone to magnesium deficiency include:

An unhealthy digestive system, which impairs your body’s ability to absorb magnesium (Crohn’s disease, leaky gut, etc.) Diabetes, especially if it’s poorly controlled, leading to increased magnesium loss in urine Age — older adults are more likely to be magnesium deficient because absorption decreases with age and the elderly are more likely to take medications that can interfere with absorption
Unhealthy kidneys, which contribute to excessive loss of magnesium in urine Alcoholism — up to 60 percent of alcoholics have low blood levels of magnesium6 Certain medications — diuretics, antibiotics and medications used to treat cancer can all result in magnesium deficiency

 

To avoid magnesium deficiency, make sure you’re eating a varied, whole-food diet like the one described in my nutrition plan. Green leafy vegetables like spinach and Swiss chard are excellent sources of magnesium, as are some beans, nuts and seeds, like almonds, pumpkin seeds, sunflower- and sesame seeds. Avocados are also a good source. Juicing your greens is an excellent way to optimize your nutrition. This is my personal strategy. I typically drink one pint to one quart of fresh green vegetable juice every day, and it is one of my primary sources of magnesium.

If you decide to use a supplement, magnesium threonate is likely one of the best sources of magnesium as it seems to penetrate cell membranes, including the mitochondria, which results in higher energy levels. Additionally it also penetrates the blood-brain barrier and seems to do wonders to treat and prevent dementia and improve memory.

Balance Your Magnesium with Calcium, Vitamin K2 and D

One of the major benefits of getting your nutrients from a varied whole food diet is that you’re far less likely to end up with too much of one nutrient at the expense of others. Foods in general contain all the cofactors and needed co-nutrients in the proper amounts for optimal health, which takes out the guess work. When you’re using supplements, you need to become a bit more savvy about how nutrients influence and synergistically affect each other.

For example, it’s important to maintain the proper balance between magnesium, calcium, vitamin K2, and vitamin D. These all work together synergistically, and lack of balance between these nutrients is why calcium supplements have become associated with increased risk of heart attacks and stroke, and why some people experience vitamin D toxicity. To learn more about this, please see this previous article that delves into this at some depth.

Do You Need More Potassium in Your Diet?

Potassium is an essential mineral “salt” that is sometimes referred to as the “good salt.” It’s most commonly known for its role in blood pressure regulation, and it works synergistically with magnesium to improve sleep, among other things. This combination may be of particular benefit if muscle cramps are keeping you awake.

As an electrolyte, potassium is a positive charged ion that must maintain a certain concentration7 in order to carry out its functions, which includes interacting with sodium to help control nerve impulse transmission, muscle contraction and heart function. In fact, maintaining the proper ratio of potassium to sodium is an important factor for optimal health. It’s generally recommended that you take in five times more potassium than sodium8, but because most Americans’ diets are so rich in high-sodium processed foods, most people get double the amount of sodium compared to potassium from their diet.

If you have high blood pressure, it could be a sign that you’re lacking in this vital mineral or that your ratio of potassium to sodium is upside-down from an improper diet. Signs of severe potassium deficiency include fatigue, muscle weakness, abdominal pain and cramps, and in severe cases abnormal heart rhythms and muscular paralysis. The ideal way to increase your potassium is to obtain it from vegetables, such as:

Swiss chard (960 mg of potassium per 1 cup) Spinach (838 mg per cup) Broccoli (505 mg per cup) Celery (344 mg per cup)
Avocado (874 mg per cup) Crimini mushrooms (635 mg in 5 ounces) Brussels sprouts (494 mg per cup) Romaine lettuce (324 mg per 2 cups)

Vitamin D Deficiency May Be the Cause of Excessive Sleepiness

A growing body of research clearly shows the absolute necessity of vitamin D for good health and disease prevention, and it may even play an important role in sleep. According to research presented at last year’s Associated Professional Sleep Societies meeting, people with daytime sleepiness and musculoskeletal pain, which can easily sabotage sleep, are likely to have vitamin D insufficiency or deficiency. According to a writeup by Mother Nature Network9:

“[T]he team decided to test the vitamin D levels of patients who had complained of chronic pain as part of the workup that was done for other sleep disturbances. McCarty and colleagues performed research and reviews of 153 patients at a sleep clinic. Eighty-four percent of patients had either vitamin D insufficiency (30 percent) or deficiency (54 percent).

They discovered that some patients who exhibited low levels of vitamin D experienced complete resolution of daytime sleepiness symptoms after treatment for vitamin D deficiency. McCarty and colleagues concluded that it is biologically plausible that low vitamin D could contribute to sleepiness because of its role in systemic inflammation.”

Vitamin D3 is an oil-soluble steroid hormone (the term “vitamin” is a misnomer) that forms when your skin is exposed to UVB radiation from the sun or a safe tanning bed. When UVB strikes the surface of your skin, your skin converts a cholesterol derivative into vitamin D3, and this is, by far, the best way to optimize your vitamin D levels.

If you opt for a vitamin D supplement, you also need to boost your intake of vitamin K2 through food and/or a supplement. How do you know if your vitamin D level is in the right range? The most important factor is having your vitamin D serum leveltested every six months, as people vary widely in their response to ultraviolet exposure or oral D3 supplementation. Your goal is to reach a clinically relevant serum level of 50-70 ng/ml. As a general guideline, research by GrassrootsHealth suggests that adults need about 8,000 IU’s per day to achieve a serum level of 40 ng/ml.

Tips to Help You Sleep Better

Besides nutritional deficiencies, there are many other variables that can impact how well you sleep. I suggest you read through my full set of 33 healthy sleep guidelines for all of the details, but to start, making some adjustments to your sleeping area can go a long way to ensure uninterrupted, restful sleep.

  1. Cover your windows with blackout shades or drapes to ensure complete darkness. Even the tiniest bit of light in the room can disrupt your pineal gland’s production of melatonin and the melatonin precursor serotonin, thereby disrupting your sleep cycle.

So close your bedroom door, get rid of night-lights, and refrain from turning on any light during the night, even when getting up to go to the bathroom. If you have to use a light, install so-called “low blue” light bulbs in your bedroom and bathroom. These emit amber light that will not suppress melatonin production.

  1. Keep the temperature in your bedroom at or below 70 degrees F (21 degrees Celsius). Many people keep their homes and particularly their upstairs bedrooms too warm. Studies show that the optimal room temperature for sleep is quite cool, between 60 to 68 degrees F (15.5 to 20 C). Keeping your room cooler or hotter can lead to restless sleep.
  2. Check your bedroom for electro-magnetic fields (EMFs). These can also disrupt your pineal gland’s production of melatonin and serotonin, and may have other negative effects as well. To do this, you need a gauss meter. You can find various models online, starting around $50 to $200. Some experts even recommend pulling your circuit breaker before bed to kill all power in your house.
  3. Move alarm clocks and other electrical devices away from your head. If these devices must be used, keep them as far away from your bed as possible, preferably at least three feet.
  4. Reduce use of light-emitting technology, such as your TV, iPad, and computer, before going to bed. These emit the type of light that will suppress melatonin production, which in turn will hamper your ability to fall asleep, as well as increase your cancer risk (melatonin helps to suppress harmful free radicals in your body and slows the production of estrogen, which can contribute to cancer). Ideally, you’ll want to turn all such light-emitting gadgets off at least one hour prior to bedtime.

As previously discussed by Dr. Rubin Naiman, a leader in integrative medicine approaches to sleep and dreams, sleep is the outcome of an interaction between two variables, namely sleepiness and what he refers to as “noise.” This is any kind of stimulation that inhibits or disrupts sleep. In order to get a good night’s sleep, you want your sleepiness level to be high, and the “noise” level to be low. Under normal conditions, your sleepiness should gradually increase throughout the day and evening, peaking just before you go to bed at night. However, if noise is conceptually greater than your level of sleepiness, you will not be able to fall asleep.

Improving Your Nutrition May Help You Sleep Better

If you aren’t sleeping well, it is just a matter of time before it will adversely affect your health, even if you’re doing everything else right. Fortunately, there are many simple solutions to address poor sleep, starting with your diet and lifestyle. Certain nutrients, such as melatonin, magnesium, potassium and vitamin D can play an important role. It’s also crucial to pay attention to your use of artificial lighting. To promote good sleep, make sure you’re exposed to full natural light during the day, and avoid artificial lighting once the sun goes down, especially as bedtime draws near.

To make your bedroom into a suitable sleep sanctuary, begin by making sure it’s pitch-black, cool, and quiet. Remember, even the tiniest bit of light can disrupt your pineal gland’s production of melatonin and serotonin. For this reason, I highly recommend adding room-darkening blinds or drapes to your bedroom, or if this is not possible wearing an eye mask to block out any stray light.

For even more helpful guidance on how to improve your sleep, please review my 33 Secrets to a Good Night’s Sleep. If you’re even slightly sleep deprived I encourage you to implement some of these tips tonight, as high-quality sleep is one of the most important factors in your health and quality of life.

Source: mercola.com

 

5 Tips for Recovering from Emotional Pain

  1. If you allow yourself to feel helpless after a failure, or blame it on your lack of ability or bad luck, it’s likely to lower your self-esteem. Blaming a failure on specific factors within your control, such as planning and execution, is likely to be less damaging, but even better is focusing on ways you can improve and be better informed so you can succeed next time.
    1. Emotional pain often exacts a greater toll on your quality of life than physical pain. The stress and negative emotions associated with any trying event can even lead to physical pain and disease.
    2. In fact, emotional stress is linked to health problems including chronic inflammation, lowered immune function, increased blood pressure, altered brain chemistry, increased tumor growth and more.
    3. Of course, emotional pain can be so severe that it interferes with your ability to enjoy life and, in extreme cases, may even make you question whether your life is worth living.
    4. As the featured article reported, Guy Winch, author of Emotional First Aid: Practical Strategies for Treating Failure, Rejection, Guilt and Other Everyday Psychological Injuries, recently shared five tips for healing your emotional pain.
    5. 1. Let Go of Rejection
    6. Rejection actually activates the same pathways in your brain as physical pain, which is one reason why it hurts so much. The feeling of rejection toys with your innate need to belong, and is so distressing that it interferes with your ability to think, recall memories and make decisions. The sooner you let go of painful rejections, the better off your mental health will be.
    7. 2. Avoid Ruminating
    8. When you ruminate, or brood, over a past hurt, the memories you replay in your mind only become increasingly distressing and cause more anger – without providing any new insights. In other words, while reflecting on a painful event can help you to reach an understanding or closure about it, ruminating simply increases your stress levels, and can actually be addictive.
    9. Ruminating on a stressful incident can also increase your levels of C-reactive protein, a marker of inflammation in your body linked to cardiovascular disease.1
    10. 3. Turn Failure Into Something Positive
    11. If you allow yourself to feel helpless after a failure, or blame it on your lack of ability or bad luck, it’s likely to lower your self-esteem. Blaming a failure on specific factors within your control, such as planning and execution, is likely to be less damaging, but even better is focusing on ways you can improve and be better informed or prepared so you can succeed next time (and try again, so there is a next time).
    12. 4. Make Sure Guilt Remains a Useful Emotion
    13. Guilt can be beneficial in that it can stop you from doing something that may harm another person (making it a strong ‘relationship protector). But guilt that lingers or is excessive can impair your ability to focus and enjoy life.
    14. If you still feel guilty after apologizing for a wrongdoing, be sure you have expressed empathy toward them and conveyed that you understand how your actions impacted them. This will likely lead to authentic forgiveness and relief of your guilty feelings.
    15. 5. Use Self-Affirmations if You Have Low Self-Esteem
    16. While positive affirmations are excellent tools for emotional health, if they fall outside the boundaries of your beliefs they may be ineffective. This may be the case for people with low self-esteem, for whom self-affirmations may be more useful. Self-affirmations, such as “I have a great work ethic” can help to reinforce positive qualities you believe you have, as can making a list of your best qualities.
    17. Many, if not most, people carry emotional scars — traumas that can adversely affect your health and quality of life. Using techniques like energy psychology, you can correct the emotional short-circuiting that contributes to your chronic emotional pain. My favorite technique for this is the Emotional Freedom Technique (EFT), which is the most comprehensive and most popular version of energy psychology. EFT is a form of psychological acupressure based on the same energy meridians used in traditional acupuncture to treat physical and emotional ailments for over 5,000 years, but without the invasiveness of needles.
    18. Instead, simple tapping with the fingertips is used to transfer kinetic energy onto specific meridians on your head and chest while you think about your specific problem — whether it is a traumatic event, an addiction, pain, anxiety, etc. — and voice positive affirmations.
    19. This combination of tapping the energy meridians and voicing positive affirmation works to clear the “short-circuit”—the emotional block—from your body’s bioenergy system, thus restoring your mind and body’s balance, which is essential for optimal health and the healing of physical disease. The beauty about EFT is that it can reprogram your body’s reactions to the unavoidable stressors of everyday life, thereby providing a more lasting effect.
    20. More than any traditional or alternative method I have used or researched, EFT has the most potential to literally work magic. Clinical trials have shown that EFT is able to rapidly reduce the emotional impact of memories and incidents that trigger emotional distress. Once the distress is reduced or removed, your body can often rebalance itself, and accelerate healing.
    21. For a demonstration of how to perform EFT, please see the video below featuring EFT practitioner Julie Schiffman. The first video is a general demonstration, which can be tailored to just about any problem, and the second demonstrates how to tap for depression. While this technique is particularly effective for relieving emotional or mental stress and anxiety, it can be used for all manner of physical pain relief as well.

5.    5 Tips for Healing Emotional Pain

19.  My Most Highly Recommended Tool for Emotional Healing

Emotional Health Takes Ongoing Care: 9 More Tips for Well-Being

Just as eating healthy, exercising and getting a good night’s sleep are habits that must be held to in the long run to be effective, your emotional health requires ongoing care as well. And, just like your physical body, your mind can only take so much stress before it breaks down. Yet many neglect to tend to their emotional health with the same devotion they give to their physical well-being. This is a mistake, but one that’s easily remedied with the following tips for emotional nurturing.2

1. Be an Optimist

Looking on the bright side increases your ability to experience happiness in your day-to-day life while helping you cope more effectively with stress.

2. Have Hope

Having hope allows you to see the light at the end of the tunnel, helping you push through even dark, challenging times. Accomplishing goals, even small ones, can help you to build your level of hope.

3. Accept Yourself

Self-deprecating remarks and thoughts will shroud your mind with negativity and foster increased levels of stress. Seek out and embrace the positive traits of yourself and your life, and avoid measuring your own worth by comparing yourself to those around you.

4. Stay Connected

Having loving and supportive relationships helps you feel connected and accepted, and promote a more positive mood. Intimate relationships help meet your emotional needs, so make it a point to reach out to others to develop and nurture these relationships in your life.

5. Express Gratitude

People who are thankful for what they have are better able to cope with stress, have more positive emotions, and are better able to reach their goals. The best way to harness the positive power of gratitude is to keep a gratitude journal or list, where you actively write down exactly what you’re grateful for each day. Doing so has been linked to happier moods, greater optimism and even better physical health.

6. Find Your Purpose and Meaning

When you have a purpose or goal that you’re striving for, your life will take on a new meaning that supports your mental well-being. If you’re not sure what your purpose is, explore your natural talents and interests to help find it, and also consider your role in intimate relationships and ability to grow spiritually.

7. Master Your Environment

When you have mastery over your environment, you’ve learned how to best modify your unique circumstances for the most emotional balance, which leads to feelings of pride and success. Mastery entails using skills such as time management and prioritization along with believing in your ability to handle whatever life throws your way.

8. Exercise Regularly

Exercise boosts levels of health-promoting neurochemicals like serotonin, dopamine, and norepinephrine, which may help buffer some of the effects of stress and also relieve some symptoms of depression. Rather than viewing exercise as a medical tool to lose weight, prevent disease, and live longer – all benefits that occur in the future – try viewing exercise as a daily tool to immediately enhance your frame of mind, reduce stress and feel happier.

9. Practice Mindfulness

Practicing “mindfulness” means that you’re actively paying attention to the moment you’re in right now. Rather than letting your mind wander, when you’re mindful you’re living in the moment and letting distracting or negative thoughts pass through your mind without getting caught up in their emotional implications. Mindfulness can help you reduce stress for increased well-being as well as achieve undistracted focus.

Physical Health Also Supports Emotional Health and Healing

It’s a mistake to view your emotional health as a separate entity from your physical health, as the two are intricately connected. You’ll have an easier time bouncing back from emotional setbacks when you’re physically well, and healthy habits will also help keep your mood elevated naturally in the midst of stress. Happy people tend to be healthy people, and vice versa, so in addition to the tips above, the following lifestyle strategies can also help to support emotional wellness and healing:

  • Eat well: What you eat directly impacts your mood and energy levels in both the short and long term. Whereas eating right can prime your body and brain to be in a focused, happy state, eating processed junk foods will leave you sluggish and prone to chronic disease. My free nutrition plan is an excellent tool to help you choose the best foods for both physical and emotional wellness.
  • Proper sleep: Sleep deprivation is linked to psychiatric disorders such as anxiety and bipolar depression, while getting the right amount of sleep has been linked to positive personality characteristics such as optimism and greater self-esteem, as well as a greater ability to solve difficult problems.3
  • Animal-based omega-3 fats: Low concentrations of the omega-3 fats EPA and DHA are known to increase your risk for mood swings and mood disorders. Those suffering from depression have been found to have lower levels of omega-3 in their blood, compared to non-depressed individuals. Krill oil is my preferred source of omega-3 fats.
  • Regular sun exposure: This is essential for vitamin D production, low levels of which are linked to depression. But even beyond vitamin D, regular safe sun exposure is known to enhance mood and energy through the release of endorphins.

Source: mercola.com

 

Common fruit provide a dietary source of melatonin.

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Abstract Title:

Dietary Intake of Melatonin from Tropical Fruit Altered Urinary Excretion of 6-Sulfatoxymelatonin in Healthy Volunteers.

Abstract:

This study assessed the melatonin content of six tropical fruits and examined whether human consumption could contribute to dietary melatonin as measured by 6-sulfatoxymelatonin (aMT6-s, a marker of circulating melatonin in the body). Melatonin was extracted using methanol and analyzed by high-performance liquid chromatography. In a clinical crossover study, 30 healthy volunteers consumed selected fruits one at a time, with a 1week wash-out period between fruits, until completing all six fruits. Most fruits had moderate melatonin content. Significant increases in urine aMT6-s concentrations were seen after the consumption of pineapple (266%, p = 0.004), banana (180%, p = 0.001), and orange (47%, p = 0.007). The need to analyze melatonin both in fruit and as in vivo uptake was demonstrated. Further study is warranted regarding the clinical effect of fruit consumption in people with age-related melatonin reduction problems such as sleeplessness and illnesses involving oxidative damage.

Source: http://www.greenmedinfo.com

 

Food-Sourced Melatonin Provides Natural Way to Help Sleep.

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Studies on melatonin have documented that the body’s own melatonin production helps us fall asleep, yet research on supplemental melatonin has been disappointing. What many have missed is that certain foods provide natural forms of melatonin, which have been shown to raise melatonin blood levels naturally and significantly aid sleep.

An abundance of research has linked higher melatonin levels with the ability to fall asleep. Yet this research has been done on the body’s own melatonin production. Melatonin production is stimulated by the pineal gland as the sun sets and the lights dim during the later evening. This helps us fall asleep, as melatonin helps slow down cellular metabolism.

food_source_melatonin

As most of us age, and especially with higher stress levels, our body’s ability to produce melatonin wanes. This can produce a chronic issue of sleeplessness – which has the potential for producing greater risk of various disorders as we age – as lack of sleep quality has been linked with a myriad of chronic disorders, from chronic fatigue to dementia.

Does Supplement Melatonin Work and Is It Safe?

Yet synthetic melatonin – either produced in the lab or from cow urine – does not produce the same effects as the body’s own (endogenous) melatonin. Some studies have shown that synthetic melatonin can help ones sleep-phase cycles slightly – helping during jet lag or similar situations – when our sleep cycles get messed up.

But as a sleep inducer – synthetic melatonin has been disappointing at best. Some research – such as studies by Dement and Vaughan (1999) – has even found that synthetic melatonin can stunt growth among younger people along with producing a myriad of other side effects such as dizziness and headaches.

Furthermore, supplemental melatonin’s effectiveness as a sleep aid has been shown to be questionable. In an extensive review by researchers from the University of Alberta (Buscemi et al. 2004) prepared for the U.S. Department of Health and Human Services, 932 studies on melatonin since 1999 were analyzed—with 132 being qualified as offering clear results with good protocols. The study concluded that supplemental melatonin was:
• Not effective for treatment of most primary sleep disorders
• Not effective in treating most secondary sleep disorders
• Offered no evidence of effectiveness for jet lag and shift-worker disorders

Certain Natural Foods Provide a Safe Means of Melatonin

Yet little attention has been put on the fact that nature provides another means for increasing blood melatonin levels – by eating certain natural foods.

And recently, research from Thailand’s Khon Kaen University has found that the body’s levels of melatonin can be naturally raised through eating of some tropical fruits.

The researchers used a crossover study design with 30 healthy human subjects to see which fruits – tropical fruits selected for their melatonin content – would naturally raise the body’s melatonin levels.

The researchers tested six tropical fruits among the volunteers, giving them a diet heavy in that particular fruit for one week following a one-week washout. During these periods the researchers analyzed the subjects’ urine levels of 6-sulfatoxymelatonin – also referred to as aMT6s.

Higher levels of 6-sulfatoxymelatonin or aMT6s in the urine indicates higher levels of melatonin circulating within the bloodstream.

With each different fruit, the subjects’ aMT6s levels were tested. The 6-sulfatoxymelatonin (aMT6s) levels after eating some fruits – notably pineapples, bananas and oranges – increased significantly. Pineapples increased 6-sulfatoxymelatonin (aMT6s) levels by over two-and-a-half times (266%) while banana increased aMT6s levels by 180% – almost double. Meanwhile, oranges increased aMT6s levels by 47%.

The other fruits also moderately increased melatonin content among the patients.

Learn more about natural ways to boost melatonin levels and over 200 other natural remedies for getting to sleep.

Other Foods also Provide Melatonin Safely

Other research – as reported by Realnatural – has shown that natural melatonin from red tart Montmorency cherries (Prunus cerasus) can increase sleep efficiency and quality. A study from an international group of researchers found that drinking tart cherry juice for seven days increased sleep by an average of 34 minutes a night – by speeding up falling to sleep – and increased sleep efficiency by 5-6%.

And like the study from Thailand, the research found that drinking cherry juice increased 6-sulfatoxymelatonin levels naturally – without the need of exogenous or synthetic melatonin supplements.

Other foods that naturally increase melatonin levels include oats, sweet corn, rice, ginger, tomatoes, bananas, mangosteen and barley.

Source: Nature

Helpful Tips for Sleeping Better This Summer.

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Story at-a-glance

  • Nearly 41 million US adults are sleeping just six hours or less each night, which recent research has linked to an increased risk of chronic inflammation and heart disease in women
  • Men with restless legs syndrome have a 40 percent higher risk of total mortality. According to the researchers, one of several potential mechanisms that might account for this increased mortality risk is disturbed sleep
  • Sleeping pills have been linked to a wide variety of health hazards, including a nearly four-fold increase in the risk of death, along with a 35 percent increased risk of cancer
  • Tips for better sleep are discussed, including the critical elements of your sleeping sanctuary, when to exercise to promote sleep, foods and beverages to avoid before bedtime, and the effect of electronic gadgets
  • Using EFT and/or increasing your melatonin can usually offer help when nothing else seems to work.
  • Man sleeping

If you’re like most Americans, you’re likely not getting enough sleep. Nearly 41 million US adults are sleeping just six hours or less each night, which recent research has linked to an increased risk of chronic inflammation and heart disease in women.1

Over the course of the five-year long study,2 women who slept poorly—quantified as sleeping less than six hours per night—had 2.5 times higher increases in inflammation levels compared to men who slept poorly. As reported by the featured article:3

“Researchers speculated that the gender difference may be due to lower estrogen levels in the study’s post-menopausal female subjects, whereas men were protected by higher levels of testosterone.”

But regardless of gender-based hormonal differences, summertime can be a time of year when sleep becomes harder to come by, courtesy of rising temperatures. This is just one of a whole host of factors that can have an adverse effect on your sleep. Restless legs syndrome is another ailment that can prevent you from getting sufficient amounts of shut-eye.

Interestingly, a recent observational study4 found that men with restless legs syndrome have a whopping 40 percent higher risk of total mortality. This finding was independent of other known risk factors, including a variety of chronic diseases. As reported by MedPage Today:5

“The relationship between restless legs syndrome and all-cause mortality was stronger for men who had symptoms 15 or more times per month compared with those who had symptoms five to 14 times per month.”

According to the researchers, one (of several) potential mechanisms that might account for this increased mortality risk is disturbed sleep. Previous research has also found that people with chronic insomnia have a three times greater risk of dying from any cause.

summer-sleep

Sleep Deprivation Takes a Serious Toll on Your Health…

You can have the healthiest diet on the planet, doing vegetable juicing and using fermented veggies, be as fit as an Olympic athlete, be emotionally balanced, but if you aren’t sleeping well it is just a matter of time before it will adversely, potentially seriously affect your health.

Sleep deprivation is such a chronic condition these days that you might not even realize you suffer from it. Science has now established that a sleep deficit can have serious, far reaching effects on your health. For example, interrupted or impaired sleep can:

  • Dramatically weaken your immune system
  • Accelerate tumor growth—tumors grow two to three times faster in laboratory animals with severe sleep dysfunctions, primarily due to disruptedmelatonin production. Melatonin inhibits the proliferation of a wide range of cancer cell types, as well as triggering cancer cell apoptosis (self destruction). The hormone also interferes with the new blood supply tumors require for their rapid growth (angiogenesis)
  • Cause a pre-diabetic state, making you feel hungry even if you’ve already eaten, which can wreak havoc on your weight
  • Seriously impair your memory; even a single night of poor sleep—meaning sleeping only 4 to 6 hours—can impact your ability to think clearly the next day. It’s also known to decrease your problem solving ability

What You Need to Know About Sleeping Pills

While it may be tempting to look for a pill to quickly help you sleep, these will notaddress any of the underlying causes of insomnia. In fact, researchers have repeatedly shown that sleeping pills don’t work, but your brain is being tricked into thinking they do…

In one meta-analytic study, they found that, on average, sleeping pills help people fall asleep approximately 10 minutes sooner. From a biomedical perspective, this is an insignificant improvement. On average, sleeping pills increase total sleep time by about 15-20 minutes. But here is the catch: This study also discovered that while most sleeping pills created poor, fragmented sleep, they also createdamnesia, so upon waking, the participants could not recall how poorly they’d actually slept!

Worse yet, sleeping pills have also been linked to a wide variety of health hazards, including a nearly four-fold increase in the risk of death, along with a 35 percent increased risk of cancer.

Additionally, most people do not realize that over-the-counter (OTC) sleeping pills — those containing Benadryl — can have a half life of about 18 hours. So, if you take them every night, you’re basically sedated much of the time. Not surprisingly, they’re associated with cognitive deficits in the morning. Trust me, there are far better, safer and more effective ways to get a good night’s sleep…

Tips for High-Quality Shut-Eye from a Sleep Wellness Consultant

As previously discussed by Dr. Rubin Naiman, a leader in integrative medicine approaches to sleep and dreams, sleep is the outcome of an interaction between two variables, namely sleepiness and what he refers to as “noise.” This is any kind of stimulation that inhibits or disrupts sleep. In order to get a good night’s sleep, you want your sleepiness level to be high, and the “noise” level to be low. Under normal conditions, your sleepiness should gradually increase throughout the day and evening, peaking just before you go to bed at night. However, if noise is conceptually greater than your level of sleepiness, you will not be able to fall asleep.

n a recent CNN article, 6 sleep wellness consultant Nancy Rothstein offered up six tips to improve your sleep, wisely starting off by addressing environmental “noise” in your bedroom (for the rest of her suggestions, please see the original article):7

  • Create a sleep sanctuary. This means removing items associated with entertainment, recreation, work and hobbies, and turning your bedroom into a single-purpose space—one for sleeping. Of utmost importance: Make sure your bedroom iscool, dark and quiet. These three factors can have a major impact on your sleep.

With regards to temperature, studies show that the optimal room temperature for sleep is quite cool, between 60 to 68 degrees Fahrenheit, so keep the temperature in your bedroom no higher than 70 degrees.

As for light, even the tiniest bit of light in the room can disrupt your internal clock and your pineal gland’s production of melatonin and serotonin, hormones involved in your body’s circadian rhythm of sleep and wakefulness. So close your bedroom door, get rid of night-lights, and most importantly, cover your windows. I recommend using blackout shades or heavy, opaque drapes. Also cover up your clock if it has a lit display. Alternatively, you could wear an eye mask to block out any stray light.

  • Turn off your gadgets well before bedtime. Again, the artificial glow from your TV, iPad, computer or smartphone can serve as a stimulus for keeping you awake well past your bedtime by disrupting melatonin production. I recommend turning off all electronic gadgets at least one hour before bed. As Rothstein suggests, that time is far better spent reading a good old fashioned book, practicing relaxation techniques or meditating.

Some people find the sound of white noise or nature sounds, such as the ocean or forest, to be soothing and sleep-promoting. An excellent relaxation/meditation option to listen to before bed is the Insight audio CD. Another favorite is theSleep Harmony CD, which uses a combination of advanced vibrational technology and guided meditation to help you effortlessly fall into deep delta sleep within minutes. The CD works on the principle of “sleep wave entrainment” to assist your brain in gearing down for sleep.

  • Exercise to sleep better, but do it early! Exercising for at least 30 minutes per day can improve your sleep, but if you exercise too close to bedtime (generally within the three hours before), it may keep you awake instead.
  • Party-goers beware: alcohol tends to prevent good sleep… Summertime tends to spark party invitations, but as Rothstein warns, it would be wise to consider how a few drinks will affect your sleep pattern. Although alcohol will make you drowsy, the effect is short lived and you will often wake up several hours later, unable to fall back asleep. Alcohol can also keep you from entering the deeper stages of sleep, where your body does most of its healing.

The same applies to eating. Ideally, you’ll want to avoid eating or snacking at least three hours before bed. Especially troublesome are grains and sugars, as these will raise your blood sugar and delay sleep. Later, when your blood sugar drops, you may wake up and be unable to fall back asleep.

Two More Aces Up Your Sleeve When Sleep Becomes Elusive…

My personal favorite fix for insomnia is the Emotional Freedom Techniques (EFT). Most people can learn the basics of this gentle tapping technique in a few minutes. EFT can help balance your body’s bioenergy system and resolve some of the emotional stresses that are contributing to your insomnia at a very deep level. The results are typically long lasting and improvement is remarkably rapid.

Another strategy that can help is to increase your melatonin. Ideally it is best to increase your levels naturally, by exposing yourself to bright sunlight during daytime hours (along with full spectrum fluorescent bulbs in the winter) followed by absolute complete darkness at night. If that isn’t possible, you may want to consider a melatonin supplement. In scientific studies, melatonin has been shown to increase sleepiness, help you fall asleep more quickly and stay asleep, decrease restlessness, and reverse daytime fatigue. Melatonin is a completely natural substance, made by your body, and has many health benefits in addition to sleep.

If you decide to give melatonin supplements a try, start with a very small dose, about an hour before bed—as little as 0.25 mg can be sufficient for some.8 Many end up taking too much right off the bat, which could end up having the reverse effect you’re looking for. Taking too much could also result in side effects9 such as drowsiness, confusion, headache, nightmares, and more. So, start with a tiny dose, and if after three nights you notice no improvement, take a little more. The tips discussed so far are among the most important for a restful night’s sleep, but they are only the beginning. For more, please read my comprehensive sleep guide:33 Secret’s to a Good Night’s Sleep.

Improving Your Sleep Hygiene Pays Off in Health Dividends

There’s convincing evidence showing that if you do not sleep enough, you’re really jeopardizing your health. Everybody loses sleep here and there, and your body can adjust for temporary shortcomings. But if you develop a chronic pattern of sleeping less than five or six hours a night, then you’re increasing your risk of a number of health conditions, including heart disease.

To make your bedroom into a suitable sleep sanctuary, begin by making sure it’s pitch-black, cool, and quiet. Remember, even the tiniest bit of light can disrupt your pineal gland’s production of melatonin and serotonin. For this reason, I highly recommend adding room-darkening blinds or drapes to your bedroom, or if this is not possible wearing an eye mask to block out any stray light.

For even more helpful guidance on how to improve your sleep, please review my 33 Secrets to a Good Night’s Sleep. If you’re even slightly sleep deprived, I encourage you to implement some of these tips tonight, as high-quality sleep is one of the most important factors in your health and quality of life.

Source: mercola.com

 

Restless legs syndrome: pathophysiology and modern management.

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Restless legs syndrome (RLS) is a common sensory motor neurological disorder that is characterised by an irresistible urge to move the legs that significantly affects the quality of life of the patient. Prevalence in the general population is 5-25% and it is twice as prevalent in women as in men. RLS is the most common movement disorder in pregnancy with a fourfold increased risk of developing this disorder later in life. The pathophysiology of RLS is centred on dopaminergic dysfunction, reduced central nervous system iron, genetic linkages, or alteration in neurotransmitters such as hypocretins, endorphins levels and immune dysfunction and inflammatory mechanisms. With the emergence of new evidence, there are changes to the previous treatment recommendations for RLS. There is sufficient evidence to conclude that dopamine agonists such as rotigotine transdermal patch, pramipexole, ropinirole, gabapentin enacarbil, pregabalin and gabapentin are effective in the short-term treatment of RLS and rotigotine, followed by gabapentin enacarbil, ropinirole, pramipexole and gabapentin for long-term treatment. Based on expert consensus, the recommendation for daily RLS is dopamine agonists or gabapentin or low-potency opioids. Levodopa is less preferred for treating daily RLS due to its high risk of augmentation. For intermittent RLS, it is levodopa or dopamine agonists or low-potency opioids or benzodiazepines. For refractory RLS, the choice is to change to gabapentin or a different dopamine agonist, addition of a second agent like gabapentin or benzodiazepine to the existing drug or changing to a high-potency opioid or tramadol. Medications with safety record in pregnancy include opioids and antiepileptics such as carbamazepine and gabapentin. There are concerns that patients with RLS are at risk for metabolic deregulation, autonomic dysfunction and cardiovascular morbidity. However, a recent study concluded that RLS is not associated with increased risk of cardiovascular complications.

Source: Source: PMJ. BMJ

 

Obstructive sleep apnoea and type 2 diabetes mellitus: a bidirectional association.

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Obstructive sleep apnoea and type 2 diabetes are common medical disorders that have important clinical, epidemiological, and public health implications. Research done in the past two decades indicates that obstructive sleep apnoea, through the effects of intermittent hypoxaemia and sleep fragmentation, could contribute independently to the development of insulin resistance, glucose intolerance, and type 2 diabetes. Conversely, type 2 diabetes might increase predisposition to, or accelerate progression of, obstructive and central sleep apnoea, possibly through the development of peripheral neuropathy and abnormalities of ventilatory and upper airway neural control. Although more research is needed to clarify the mechanisms underlying the bidirectional association between the two disorders, their frequent coexistence should prompt all health-care professionals to embrace clinical practices that include screening of a patient presenting with one disorder for the other. Early identification of obstructive sleep apnoea in patients with metabolic dysfunction, including type 2 diabetes, and assessment for metabolic abnormalities in those with obstructive sleep apnoea could reduce cardiovascular disease risk and improve the quality of life of patients with these chronic diseases.

Source: lancet

 

 

Severe Sleep Apnea Associated with Higher Risk for Sudden Cardiac Death.

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Sleep apnea severity is an independent and significant predictor of sudden cardiac death (SCD), according to a study in the Journal of the American College of Cardiology.

Researchers recruited some 11,000 consecutive patients undergoing first-time polysomnography studies and followed them for an average of 5 years to document incidents of resuscitated or fatal SCD. Over the course of the study, the annual rate of SCD was 0.27%.

In multivariable analysis, having a lowest nocturnal oxygen saturation of less than 78% was associated with an increased risk for SCD (hazard ratio, 1.81). An apnea-hypopnea index above 20 events per hour was also associated with an increased risk.

The authors speculate that the repetitive oxygen desaturations associated with sleep apnea may cause ventricular ectopy and dysrhythmias; they also observe that these patients show an increase in nighttime coagulability.

Source: Journal of the American College of Cardiology

 

The Effect of Dexlansoprazole MR on Nocturnal Heartburn and GERD-Related Sleep Disturbances in Patients With Symptomatic GERD.

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OBJECTIVES:

 

Nocturnal heartburn and related sleep disturbances are common among patients with gastroesophageal reflux disease (GERD). This study evaluated the efficacy of dexlansoprazole MR 30 mg in relieving nocturnal heartburn and GERD-related sleep disturbances, improving work productivity, and decreasing nocturnal symptom severity in patients with symptomatic GERD.

METHODS:

 

Patients (N=305) with frequent, moderate-to-very severe nocturnal heartburn and associated sleep disturbances were randomized 1:1 in a double-blind fashion to receive dexlansoprazole MR or placebo once daily for 4 weeks. The primary end point was the percentage of nights without heartburn. Secondary end points were the percentage of patients with relief of nocturnal heartburn and of GERD-related sleep disturbances over the last 7 days of treatment. At baseline and week 4/final visit, patients completed questionnaires that assessed sleep quality, work productivity, and the severity and impact of nocturnal GERD symptoms.

RESULTS:

 

Dexlansoprazole MR 30 mg (n=152) was superior to placebo (n=153) in median percentage of nights without heartburn (73.1 vs. 35.7%, respectively; P<0.001). Dexlansoprazole MR was significantly better than placebo in percentage of patients with relief of nocturnal heartburn and GERD-related sleep disturbances (47.5 vs. 19.6%, 69.7 vs. 47.9%, respectively; P<0.001), and led to significantly greater improvements in sleep quality and work productivity and decreased nocturnal symptom severity. Adverse events were similar across treatment groups.

CONCLUSIONS:

 

In patients with symptomatic GERD, dexlansoprazole MR 30 mg is significantly more efficacious than placebo in providing relief from nocturnal heartburn, in reducing GERD-related sleep disturbances and the consequent impairments in work productivity, and in improving sleep quality/quality of life.

DISCUSSION

Dexlansoprazole MR 30 mg daily was significantly better than placebo in improving symptoms of nocturnal heartburn in symptomatic GERD patients with frequent, moderate-to-very severe nocturnal heartburn leading to improved sleep quality, and decreased symptom severity and impact on morning activities. Dexlansoprazole MR 30 mg was also effective in increasing work productivity and reducing activity impairment. It should be noted that patients enrolled in this study had to be responsive to acid-suppression therapy. This inclusion criterion was used to limit the number of functional heartburn patients enrolled in the study.

During this study, the median percentage of nights without heartburn over 4 weeks for the intent-to-treat patients receiving dexlansoprazole MR 30 mg was 73.1%. In a previous dexlansoprazole MR phase 3 study, which assessed efficacy and safety among patients with non-erosive reflux disease, this value was 80.8%(vs. 51.7% for placebo; P<0.00001) (23), supporting the results of our study. Furthermore, the therapeutic gain, or the difference between active study drug and placebo, seen in this current nocturnal heartburn study was greater than that observed in a previous phase 3 symptomatic GERD trial (37 vs. 29%) (23).

Stratification of the primary end point by baseline mean nocturnal symptom severity reveals that patients with the most severe symptoms experience the greatest therapeutic gain. Although the median percentage of nights free of nocturnal heartburn declined with increasing baseline severity, the therapeutic gain increased. The therapeutic gain experienced by patients receiving dexlansoprazole MR with severe-to-very severe baseline nocturnal symptoms is more than twice that experienced by patients with mild-to-moderate or moderate-to-severe baseline nocturnal symptoms. Patients in the severe-to-very severe group who received placebo experienced a median of 0% heartburn-free nights, while the 34 patients in the dexlansoprazole MR group reported a median of 66%of their nights as heartburn free during the 4 weeks of the trial. This could be explained by the finding that patients with more severe non-erosive reflux disease (NERD; as determined by pH testing) are more responsive to PPI therapy than patients with less severe NERD (24). This is in contrast to the response of erosive esophagitis patients receiving anti-reflux treatment (25).

During the last 7 days of the study, 48 and 70% of patients receiving dexlansoprazole MR reported relief of nocturnal heartburn and GERD-related sleep disturbances, respectively, which were significantly greater than with placebo (P<0.001 for each comparison). A similar pattern was observed by Johnson et al.(26), where patients receiving esomeprazole, 20 or 40 mg, reported higher rates of relief from GERD-related sleep disturbances from nocturnal heartburn during the last 7 days of a 4-week study.

A significantly lower frequency of GERD-related sleep disturbances was observed in the dexlansoprazole MR group. Dexlansoprazole MR resulted in a significantly lower frequency of the different types of sleep disturbances attributed to nocturnal heartburn. Of note, the percentage of nights with sleep disturbances due to other causes did not differ significantly between treatment groups. Taken together, these results suggest that patients taking dexlansoprazole MR 30 mg can expect a reduction in or relief from nocturnal heartburn symptoms and therefore better sleep quality.

Recording daily symptoms via diaries is common in clinical trials where symptom relief is a primary outcome (27). However, the limitations of this approach, particularly with paper diaries, include non-adherence (skipping entries) and “hoarding” (the retrospective completion of entries), which can lead to recall errors (28,29). Objective analyses of paper diary use have shown high rates of both non-adherence and hoarding (29). Electronic diaries, such as those used during this study, do not allow for hoarding beyond 24 h before the scheduled entry. Compliance with diary entries was high: ≥90% in 87% of patients.

The efficacy of dexlansoprazole MR for the relief of nocturnal heartburn and relief from GERD-related sleep disturbances is further supported by the improvements seen in the patient-reported outcomes. Patients receiving dexlansoprazole MR reported significantly greater improvements from baseline in sleep quality compared with placebo, which manifested as greater decreases in PSQI scores. Decreases in overall and subscale N-GSSIQ scores also showed greater efficacy for dexlansoprazole MR 30 mg compared with placebo in decreasing symptom severity, next morning impact of nocturnal symptoms, and concern regarding nocturnal GERD among the patients, thus demonstrating improvements in HRQoL. Significant improvements in HRQoL due to treatment of heartburn, both daytime and nocturnal, have been documented previously (23,26,30,31).

Accompanying these improvements in sleep quality, decreased symptom severity, and reduced impact the following morning were decreases in impairments in work productivity, as demonstrated by decreases in the WPAI scores. Treatment with dexlansoprazole MR was more effective than placebo in decreasing impairment while working and improving overall work productivity and functionality during regular activities. Furthermore, this treatment was more effective in reducing the number of work hours missed due to GERD-related sleep disturbances. These results are not unexpected when one considers the connection between repeated lack of sleep during the night and daytime sleepiness (9), as well as reduced HRQoL and work productivity (11). The negative impact of nocturnal GERD on HRQoL and work productivity is well recognized (7,8,10).

A recent survey of over 600 GERD patients on various PPI therapies found that the majority of patients continued to experience heartburn, with 83% experiencing nocturnal symptoms and almost a quarter of these patients reporting severe or very severe nocturnal symptoms (32). Daily dosing of dexlansoprazole MR 30 mg may reduce the likelihood of persistent nocturnal symptoms due to its extended duration of plasma drug levels (33); however, additional studies are needed to determine if this property equates to improved clinical outcomes.

In the above-mentioned survey (32), only approximately one-half of the patients surveyed took their PPI within the recommended 1 h to 30 min before breakfast. Poor compliance with PPI therapy is likely the most common cause for PPI failure (25). In this study, patients were to take the study drug in the morning, without regard to food. Comparable acid suppression with dexlansoprazole MR dosing has been demonstrated regardless of the timing of food intake (fasting, before or after breakfast) (34) or the time of day (before breakfast, lunch, dinner, or evening snack) (35). Although additional studies are needed to assess the impact of various dosing timings of dexlansoprazole MR on GERD symptoms, it is not unreasonable to suggest that increased flexibility in administration, and therefore increased compliance, would lead to reduced symptoms, particularly at night.

Dexlansoprazole MR 30 mg was well tolerated by patients in this current trial. Rates of treatment-emergent AEs were low and similar between the dexlansoprazole MR and placebo groups, including the premature discontinuation due to AEs. Recent analyses of pooled safety data from the phase 3 pivotal trials demonstrated that the safety profile of dexlansoprazole MR 30 mg was comparable to that of lansoprazole 30 mg (36).

The economic implications of this study are readily apparent. The favorable effect of improvement for work productivity has significant implications to payers and employers. For the patients receiving dexlansoprazole MR compared with placebo, there was an apparent work productivity advantage—$38 for the fourth week ($227 vs. $189). If these savings were extrapolated over the 4-week study, the advantage would be $152/treated patient. This type of modeling allows for the development of a business plan for payers–employers to evaluate the cost benefits of effective therapy. By this type of analysis, the “investment” cost of therapy can be analyzed against the returns of improved work productivity.

This study has several limitations, the first being the lack of an active comparator, another PPI. Although direct comparisons of efficacy results from different trials cannot be made, a recent review comparing the efficacy of various PPIs (not including dexlansoprazole MR) in relieving or resolving nocturnal heartburn in a clinical trial setting found no outstanding differences in efficacy between comparable doses (37). Placebo has been the standard comparator used in other studies assessing the efficacy of a PPI for nocturnal heartburn and in all studies of GERD-related sleep disturbances (23,26,38).

A second limitation is the lack of pH monitoring to document the level of acid suppression or to distinguish symptomatic non-erosive reflux from functional heartburn. It is difficult to attribute any symptom to reflux without direct esophageal monitoring. The primary reason for no pH monitoring during this study was the potential sleep disruption caused by an intra-esophageal pH electrode. However, to mitigate lack of pH monitoring, inclusion criteria mandated previous response to acid-suppression therapy. We also did not utilize sleep labs for an objective assessment of sleep quality, which could be considered another limitation. Because a sleep lab is an artificial environment, it is likely that many patients would not have slept the same way there as they would at home. Changes in sleep quality are subjective, whether as reported in the daily diaries or in the PSQI and N-GSSIQ.

A third limitation is the assessment of response for productivity analysis limited to the fourth week of therapy. Questions remain as to what the effect is on a weekly basis beyond the early therapy effect on these particular measurements. Furthermore, an area of further research is to evaluate whether these favorable effects persist, wane, or continue to improve with extended therapy.

In summary, dexlansoprazole MR 30 mg was significantly more efficacious in providing relief from nocturnal heartburn and in reducing GERD-related sleep disturbances compared with placebo in symptomatic GERD patients with moderate-to-very severe nocturnal heartburn. This study also demonstrated significantly greater improvements in sleep quality, HRQoL, and work productivity for patients receiving dexlansoprazole MR compared with those receiving placebo.

Furthermore, there were notable economic implications with favorable advantages evident for patients treated with dexlansoprazole MR—allowing for estimates of a calculable rate of return on investment for effective therapy.

Source: Nature/AJG

 

Treating GERD Successfully: Beyond Heartburn Relief.

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A short questionnaire helps identify whether patients on therapy for GERD are experiencing sleep disturbance and might benefit from an adjustment in therapy.

Gastroesophageal reflux disease (GERD) and sleep disturbance are highly prevalent conditions that occur together in many patients. Recent studies have demonstrated that effective treatment of GERD also ameliorates related sleep dysfunction. Proton-pump inhibitors (PPIs) have been demonstrated to improve quality of life, work productivity, and driving acuity (Am J Gastroenterol 2011; 106:421). However, data have been limited to gastroenterology practice settings. In the current primary-care–based, industry-funded, cluster-randomized, open-label study, researchers evaluated the performance of a questionnaire in identifying sleep disturbance in patients being treated for GERD and, secondarily, the efficacy of esomeprazole in improving sleep disturbance.

From 180 primary care centers in Canada, 1388 patients were administered the PPI Acid Suppression Symptom (PASS) test, a validated questionnaire of five questions that identifies symptoms in patients on continuing acid-suppression therapy for GERD. One item regards sleep disturbance. Among the 825 patients who described sleep disturbance at baseline, 534 patients at 111 centers were randomized to switch from their current antisecretory therapy to once-daily esomeprazole (20 mg or 40 mg; intervention), and 291 patients at 69 centers were randomized to continue current therapy (control). At 4 weeks, 23% of patients in the intervention group versus 55% in the control group reported continued sleep disturbance (odds ratio, 2.3; 95% confidence interval, 0.17–0.32). Mean improvements in quality-of-life scores and reflux symptom scores were higher in the intervention group than in the control group.

Comment: Primary care providers (and, I suspect, many gastroenterologists) need to better recognize the implications of inadequate gastroesophageal reflux disease treatment, including sleep disturbance, which in many patients will respond to a change in acid-suppressive therapy. Whether a formal questionnaire is necessary for screening versus pragmatic and attentive questioning probably depends on the provider. Defining successful treatment for GERD means setting appropriate endpoints beyond just heartburn relief.

 

Source: Journal Watch Gastroenterology