Nutrition Essentials | The Connection Between Diet and Sleep with Nancy Foldvary-Schaeffer, DO

Podcast Transcript

John Horton:

Hello and welcome to another episode of Nutrition Essentials, an offshoot of our popular Health Essentials podcast. I'm John Horton, your host. You might not think of this when you sit down for your next meal, but the food on your plate might determine how well you sleep tonight. Science shows that certain nutrients can help you rest easier at night and allow your body to fully recharge. On the flip side, a less than stellar diet can undermine your sleep and waking up tired is no way to start the day. So today we're going to look at how what you eat affects your sleep, while also setting a menu to maximize your shut eye. As usual, we have registered dietitian, Julia Zumpano with us to help fill our grocery carts with the right stuff. When it comes to learning more about sleeping, we brought in Cleveland Clinic's version of the Mythical Sandman. Julia, can you make that introduction?

Julia Zumpano:

Absolutely, John. Our guest is Dr. Nancy Foldvary-Schaefer with the Cleveland Clinic's Sleep Disorders Center. It's safe to say she's pretty busy in her role, given research shows one in three adults don't get enough sleep at night and the numbers are even worse when it comes to teens and adolescents. Diet is an often overlooked factor when it comes to getting quality sleep needed to rise and shine in the morning. I'm looking forward to giving it some extra attention.

John Horton:

That sounds like a dreamy plan, Julia. So let's see if we can give folks something they can use to snooze.

Welcome back to the podcast, Dr. Foldvary-Schaefer. I got to tell you, I've been following some of the tips you've given us before and I am sleeping better than ever.

Dr. Nancy Foldvary Schaefer:

That's awesome, John. It's great to be here today. I take that to mean that you kicked your furry friend out of the room.

John Horton:

No, no, no, no. Charlie is still in there, but my wife likes that because we turned the temperature down because you said it's better to sleep in a cooler room, and he provides a little extra warmth so it all kind of balances out.

So we're here today, yet again, to talk about when folks have trouble sleeping, and I know when that happens, we often point kind of that accusatory finger at things like stress, aches and pains that we all have, maybe a lumpy mattress, and then there's always those not so great bedtime habits. But I know I've never really linked my overall diet to whether I'm getting the kind of snooze needed to wake up feeling refreshed. So how big of a deal can that be?

Dr. Nancy Foldvary Schaefer:

Well, it can be a significant problem for some people. Dietary change or poor diet alone is probably not one of the most common causes in isolation of sleep disturbance, but it certainly contributes. And diet choices, sleep choices and even activity choices, whether we exercise or not, in my view, are all habits. We develop bad habits, we develop good habits, and sometimes bad habits come together. So people who are not really focusing on healthy eating tend to do the kinds of things that promote poor sleep and vice versa. It's a bi-directional relationship.

John Horton:

All right, well why don't we start looking at those habits? I mean, I think we all kind of know some of the bad habit stuff and if you order that extra spicy order of wings a little too close bedtime, odds are you might be up a little bit at night. And we're going to dig into that a little bit more later.e But how exactly might what we regularly eat for breakfast, lunch, and dinner, how does that affect our sleep hours later?

Dr. Nancy Foldvary Schaefer:

Well, I think it's about what we eat and when we eat. If we eat nutritious foods, this seems to promote better quality sleep. And when we eat in regular meal times, without evening snacking and certainly without biological nighttime eating, some of us will get up in the middle of the night and eat, if timing is right and what we eat is right, then we'll promote better sleep. And in turn, if we're sleeping poorly, we're more likely to crave things that aren't good for us, sugars, for example, and we're more likely to eat more. And this is fairly evidence-based information based based on rigorous trials.

John Horton:

Yeah, well luckily this is why we have Julia here with us too because I know in getting into these really specific things that we should probably be limiting or avoiding a bit, we want to kind of get into the why with some of this. And I know one of the big ones when we were talking earlier had to do with sugars. So how is that going to keep you up at night if you have a diet that's a little too heavy on the sweet stuff?

Julia Zumpano:

So sugar can definitely cause a little more of a boost of energy. So sugar or carbohydrates are our body's main source of energy. We utilize that macronutrient to get us through our day, to fuel our day, but when we're consuming large amounts of it, we are causing spikes and drops in our blood sugar, which lead to maybe feeling more energy at one point and then more of a drop in a blood sugar so that spike and drop in your blood sugar can really affect your sleep. All of a sudden when you go to sleep, it doesn't mean you turn your entire metabolism off. Those spikes and drops can still happen throughout the night and cause you to wake up and then have trouble falling back asleep and falling back asleep. And again, restless and disrupted sleep can be a result of poor diet, specifically high sugar intake, high carbohydrate intake that's not balanced with adequate amounts of protein and healthy fats.

Then when you're consuming foods pretty close to bed, that can also negatively impact your sleep for multiple reasons, the blood sugar reason we just talked about as well as the fact that it can be hard to digest some of those foods. So especially if you're eating something heavy, heavy in fat, heavy in protein, it takes longer to digest. It can cause a little bit of a stomach upset and may cause some disruption there. You could get heartburn if you're eating more spicy foods or any foods that may trigger a reaction like heartburn or gas or bloating or anything like that-

John Horton:

That would be those wings I was talking about.

Julia Zumpano:

Exactly, exactly. Yeah. So there's a lot, like Dr. Foldvary-Schaefer said, there's a lot of good data that proves that a poor diet can really disrupt. It'd be one of the many factors that can disrupt sleep and lead to poor eating habits the next day, as she mentioned, because you're fatigued and what do we all want when we're fatigued, when we're tired? We're snacking, we're looking for food. We're looking for that energy from our food because we're lacking it internally. We're just really struggling. And what do we reach for most is carbohydrates, typically those that are simple carbs or foods that are maybe high in sugar too to get that sugar rush or that energy boost.

John Horton:

If you have that sugar in the middle of the day, are you kind of setting up that that roller coaster ride that you're talking about with your metabolism and stuff spiking and dropping, can that carry over, I mean all the way into the evening and just kind of set you up for a poor night's sleep?

Julia Zumpano:

Well, of course it's cumulative. So you have a little mini candy bar after a well-balanced lunch and then you have a very well-balanced dinner, adequate fluids in between, most likely that won't affect you at all. But it's a cumulative effect. So if you're eating poorly, you've poor balanced lunch and then you're having candy or chocolate or some sweets in the afternoon and then again another poorly balanced dinner that's maybe full of carbohydrates and fat, absolutely that can lead to it. So it's the cumulative effect of the whole picture of your day, not just a one instance intake of sugar.

John Horton:

That's just so wild because you just don't think about something you eat that far in advance of going to bed causing issues later. But it sounds like it hangs around in there and you're setting yourself up for it.

Julia Zumpano:

Well you got to think of it in terms of maybe caffeine use. So some people can have that mid, late afternoon coffee and be fine and some people they can't drink any caffeine after noon or it will negatively impact their sleep or they can only have one coffee a day. So it's just you do have to be self-aware of your reaction to certain foods and adjust based on what trends you're seeing, what habits you have throughout the day and how that may negatively impact your sleep.

John Horton:

I'm laughing as I'm looking at my cup of coffee that's sitting right here as we're doing the podcast. So I do lean on that.

Dr. Foldvary-Schaefer, know that whenever you're on, we always spend some time talking about circadian rhythm, and I'm assuming that diet has an effect on that too.

Dr. Nancy Foldvary Schaefer:

Yes, it does. The circadian rhythm, the clock in our brain regulates a number of key features of being alive, including sleep and wakefulness, our body temperature and many other things. And that circadian clock needs to be synchronized as close as possible to the light-day cycle, the light-dark cycle, the cycle of external cues around us so that we're synchronized. And certainly when we have this misalignment of the circadian clock and the outside world, our metabolism can change, our dietary choices can change. Many things happen that are not good for overall health.

So we see in studies that people who are, for example, shift workers who are working and eating when any other human would be asleep, it's biological nighttime, these are people who don't metabolize as efficiently, who tend to eat more of the foods that Julia referred to, sugars and simple carbohydrates, and then who gain weight as a result of that because they're more sedentary during their off time and they're probably not metabolizing as efficiently as they would be if they were eating during the daytime hours. So the clock system is really important when we're talking about sleep and diet.

Julia Zumpano:

Yeah, I can't agree more. One thing I do want to share is oftentimes I will encourage my patients to eat within their circadian rhythm, which the way that I explain it is that when the sun rises, you should be rising. When the sun sets, you should be trying to settle down for the evening, for the day. Again, we know seasonally it can be a little bit different. But I really try to encourage my patients not to eat anything after dinner. So kind of have that cutoff endpoint after dinner. So they give themselves a good three hour window before they're going to bed and to give their food time to settle, their body to start to kind of settle down, calm down, start to dim the lights, get ready, you have to start getting ready to go to bed. We can't immediately be in a bright kitchen and then go straight to bed and expect ourselves to fall asleep.

So I think it's really important that we try to eat, mainly consume most of our nutrient dense calories in the middle or the daylight hours is what I recommend. So even not having anything after dinner and even practicing some time restricted eating even. And if you could even push your breakfast a little later if that works for you, there's been studies that show there's a lot of benefit to eating within a smaller window and then allowing your body to rest and digest without any food for a bigger window than the eating window.

Dr. Nancy Foldvary Schaefer:

Julia, this is really an important point to reiterate I think for people with circadian rhythm disorders, which are not as common as other sleep disorders, but also for teenagers. Teens are naturally delayed in their sleep-wake cycles and they become sleep deprived because they've got to get to school on time in the morning, but they tend to be delayed. So I'm sure some of the childhood obesity that we're seeing now is due to this factor of eating too late at night.

Julia Zumpano:

Yeah, absolutely. I have a teenager at home and I always try to encourage him not to have that... He wants a bowl of cereal. I'm like, "No, you don't need it. Just wait until the morning." Trying to minimize that eating late at night to get your body ready to get to sleep. I completely agree. There's so much disruption and it does start younger and younger now.

John Horton:

Yeah, it sounds like from everything you guys are saying that our natural circadian rhythm we have where our body wants to rest at night and it's kind of programmed that way, but it sounds like we throw that off if we start eating later and especially if we start throwing certain foods in late, and I know when you start hunting around for something in the pantry at nine o'clock, it usually is not the most healthy food that you pull out of there. And I take it that then just it's this downward cycle that just is going to disrupt your sleep throughout the night.

Julia Zumpano:

Well, yeah, I think one thing you want to look at is the composition of your meals. So if you are really that hungry at nine o'clock at night, you've probably not met your nutrient needs for the day and your body's searching. I mean, some of it's habitual, we all know most eating is habitual. But you might want to look deeper at, "Am I consuming enough protein? Am I consuming enough fiber in my day? Am I consuming a good portion of healthy fats and not too many of the unhealthy saturated fats?" So I think meal composition is something extremely important. So when I have a patient, I look at their macronutrient composition of their meals, so I try to make sure it's very balanced. So making sure they're getting adequate protein, adequate fiber, those are two key things you need every time you eat, fiber, protein and then a little healthy fat. So those are essential.

So trying to minimize refined grains, really get good portions of high quality protein, adding a nice healthy fat to the meal, that balance creates satiation, you feel full, you feel satisfied, you're not necessarily searching. So it will then also minimize that snacking and also provide you energy throughout the day because we need all three macronutrients for certain forms of energy throughout our day. So they all play a very important role. So it's essential that we have good balance in all of our meals and that will create a balance in your blood sugar, which will then help extend that balance of blood sugar into the evening and create good metabolic health and make sleeping a lot easier.

John Horton:

Dr. Foldvary-Schaefer, let me ask you this, because I think we often associate whether we're getting good sleep with just the hours that we're in bed. But it's more than just that, right? If you have a bad diet and it's interrupting your sleep, it might be that you're asleep long enough, but you're just not getting that quality, high level restorative sleep that you need.

Dr. Nancy Foldvary Schaefer:

That's right. That's right. So eating poorly, especially near bedtime is likely to create more awakenings at night leading to more of what we call wake after sleep onset. So this is time that's awake in bed after someone's had their initial period of falling asleep and then shorter sleep. And again, I think about it in habitual terms. So bad habits fuel bad habits. And when we have to wake up in the morning, we're not going to feel so well because we're deprived of sleep in general, but we're probably also deprived of key deep stages of sleep and then we want to sleep longer or we stay in bed longer and then we get this rhythm that is off and it's random.

But what you're alluding to I think are the deep stages of sleep that are really critically important for health and wellness. They are deep non-REM sleep, which is stage three of-REM sleep where there is cardiovascular protection, where every cell in our body gets restored, where our tissues and muscles get restoration, and where we build up our immunity and secrete hormones. All of these critical factors happen during a stage of sleep that if we miss out on, we lose those benefits. And then REM sleep is the other. And REM happens more in the latter third of the night. But if we cut sleep short, we can selectively deprive ourselves of some of these deep stages of sleep and we surely need REM for brain development. That's why babies spend 50% of their sleep time in REM initially, and then it goes down as we get older. Brain development, memory, learning, mood regulation, all of these key important things are really dependent on these deep stages of sleep that we can cut out if we're limiting sleep duration.

Julia Zumpano:

Dr. Foldvary, one great point to note, speaking of hormones, is that sleep deprivation can lead to lack of weight loss or weight gain because it can alter the hormones that regulate your appetite, it can affect your exercise capacity, if you're deciding to exercise, it impacts decision-making. So there are hormones, ghrelin and leptin, and sleep deprivation can increase ghrelin, which is the hunger hormone and decrease leptin, which is your satiety hormone. Stress from sleep deprivation can also increase cortisol levels, which can increase appetite. And we know that sleep deprivation also increases your brain's reaction to food.

So when you have those snacks, you are more reactive to them, so you're more apt to snack more often, and then your decision-making is a little off, so you're kind of like, "Oh, well whatever. I'm hungry and I'm tired. I'm just going to keep eating. This tastes good and it feels good right now because I'm super tired or don't have any energy," right? So you can't necessarily... All odds are kind of against you. So I see a lot of times when patients have poor sleep habits and don't have good restful sleep, they really struggle with weight loss if that's one of their goals.

Dr. Nancy Foldvary Schaefer:

Yes, I agree completely. Those are great points. And I would add depression. So when we're not sleeping well, we're not only more irritable, but poor sleep is associated with depression and other mental health disorders and those types of patients tend to not get adequate exercise anyway and set themselves up for poor dietary choices. So it's a vicious cycle

Julia Zumpano:

Absolutely. I'm definitely more irritable when I don't get enough sleep.

Dr. Nancy Foldvary Schaefer:

Me too.

John Horton:

It's amazing that spiral that you guys are talking about where if you're not eating right, then that affects your sleep and when your sleep starts going downhill, you start making even worse choices when you eat, and then your sleep gets even worse and it just goes round and round and round. It makes you realize how people get into just a bad cycle and why so many of us are just tired all the time when we get up.

Dr. Nancy Foldvary Schaefer:

Right. And now in sleep medicine we're studying like health disparities, we have vulnerable populations even in the area where we work at the Cleveland Clinic who don't have access to the kinds of education, maybe don't have access to seeing a sleep expert or a nutritionist and don't have the financial resources to invest in healthy foods. And this is a pervasive problem worldwide.

Julia Zumpano:

Yeah.

John Horton:

Well, and this is also a reason why if you spend much time poking around online, there are no shortage of seemingly miracle sleep foods that get attention. I guess everyone's looking for that quick and easy answer to make everything right. So I'd like to go over some of those with you guys. I know when we talked earlier, nobody's going to prescribe these, but since they're out there a lot, just want to talk about them a little bit and why there might be a little truth to them, but why people maybe shouldn't just rely on them. And one of the big ones to start with, that seems to be the number one thing that comes up is using tart cherry juice. And I know that was kind of the star ingredient of the Sleepy Girl Mocktail that gained so much attention in the last year or so on social media. So is that going to do anything to maybe help you get those Zs?

Julia Zumpano:

Well, tart cherries are a good source of melatonin. They do contain melatonin and that's a hormone that regulates your sleep-wake cycles. And some of those Sleepy Girl Cocktails may have some magnesium powder in them or some kombucha. So the magnesium also can be very calming, very relaxing, and kombucha can kind of help that gut, the good gut bacteria, balances out the good gut bacteria a little bit, so it can kind of maybe settle an upset stomach. So I could see where there might be some truth to that, but certainly I doubt that that's going to be the cure for poor sleep.

John Horton:

I take it you're not prescribing that, Dr. Foldvary-Schaefer?

Dr. Nancy Foldvary Schaefer:

No, I'm not prescribing that so much. Melatonin is a huge topic in and of itself, but a lot of people now are using melatonin because we assume that it helps sleep, right? It's going to get us better sleep. Even I see patients who don't really have a problem with sleep quality or quantity feeling the need to use melatonin because why not? But I think it's important that melatonin is not necessarily the greatest sedative hypnotic, it's actually not that effective to help induce sleep. It's much more of a helpful time-changing agent. So by advancing our sleep time with melatonin, we might convert somebody who's a night owl who's chronically sleep deprived because that person can't fall asleep before 2:00 AM but has to be up for work at 6:00 AM into somebody who can fall asleep at 10:00 or 11:00, if given in the right dose, which is usually low and the right timing, which is usually several hours before bedtime. So melatonin's tricky because it can actually make some sleep problems worse by taking too much or by taking it too late considering the circadian cycle.

John Horton:

Let's go through some of these other, the miracle foods that come up. I saw kiwis are often touted as helping people sleep. Is there any sort of truth to that?

Julia Zumpano:

Well, kiwis contain serotonin and antioxidants that can help improve sleep. They also, again, are a good source of fiber, so can kind of settle that belly as well. So kind of the same concept.

John Horton:

See, I always love these because there's always a little kernel of truth to them, so you can see where people lean into them. But it sounds like it's just not the sort of thing where you should lean on this exclusively to try to solve some sort of sleep issue.

Julia Zumpano:

Right, absolutely.

John Horton:

What about pumpkin seeds? What's potentially magical about those?

Julia Zumpano:

So pumpkin seeds are a good source of magnesium and they're a good source of vitamin E. Again, we know magnesium is very helpful for what it comes to relaxing, get your system a little bit more calmed down, relaxing your muscles, things like that.

John Horton:

One of my favorites that popped up on the list was oily fish, which just does not sound like something I want to put down before I go to bed. But if you have it a little earlier, might it offer some sort of a help?

Julia Zumpano:

Yeah, that's part of that balance of meals and macronutrient balance. So oily fish have omega-3 fatty acids which help decrease inflammation and they're also a source of protein, so they're giving you both, which is essentially the key point here, having them consistently, which we know is very much advised on diets like the Mediterranean diet is having oily fatty fish two to three times a week. I would say that that's definitely a good thing to add into your diet for many reasons. Whether or not it affects sleep can be more of a personal observation, but not a bad thing to add in. More so for lunch or dinner, like you mentioned, not before bed.

John Horton:

Right. And I think the next one on the list, which was almonds probably falls in that same sort of category. The more healthier fat, some of these other things that might help?

Julia Zumpano:

Magnesium, same. Yeah, almonds are a source of magnesium.

John Horton:

Now the thing that stands out with all of that, those all seem like just really kind of sound dietary choices. So it's not necessarily maybe that they're magical with the sleep part of it's just that it's all part of eating a healthy diet. And as we've talked about so often on this show, Julia, I mean if you eat right, it cuts down on inflammation and so many other problems that you have. And I guess that just lends itself to being able to rest better at night.

Julia Zumpano:

Absolutely. And we know that most Americans are deficient in magnesium, which is why those magnesium rich foods are very much encouraged. But they should be encouraged regardless if you have sleep issues or not because magnesium is such an important mineral that we need in our bodies. And in some cases some people could benefit from a magnesium supplement to help sleep. Dr. Foldvary-Schaefer, how do you feel about magnesium as a supplement?

Dr. Nancy Foldvary Schaefer:

Yes, we do use that in the sleep center. And as you said, it helps people relax. I find it helps people with anxiety relax. And it's particularly helpful for people with restless legs who have this urge to move their legs at night that can really be activating and prevent sleep. This affects probably 15% of the population. And then many other people who have some irritability, whether it's peripheral neuropathy or chronic pain and, again, or mood disorder. So a little bit of magnesium we often think is sleep promoting.

John Horton:

Since we just jumped over to supplements a little bit, I want to focus on that. And I know we've talked a lot here about melatonin and magnesium, which you just kind of brought up. Those are really common supplements that people take if they're looking to address some sleep issues. So is that a good tact if you're having trouble sleeping to just head to the store and pick up a bottle to try to solve your problems?

Julia Zumpano:

I mean, I think we should look at the root cause of why you're having trouble sleeping first. So why don't we take a look at some lifestyle habits first, the composition of your meals, the timing of your meals. Are you sleeping within your circadian rhythm? Are you eating within the daylight hours? Are you getting exercise? Are you adequately hydrated? Looking at those types of things, are you managing stress in an appropriate way? So those are the things we want to look at first before we jump into a supplement. But if all of those factors you've really put time and effort into and still struggling, magnesium could be another piece of the puzzle that could support better sleep habits.

Dr. Nancy Foldvary Schaefer:

Yeah, agree entirely. Most times one of those supplements will not be the whole answer because their sleep is so complex and there are so many behavioral issues that can go wrong. And we haven't even mentioned the fact that 25 to 40% of the population, depending on what disorder we're investigating, have sleep disorders that are largely independent, so to speak, of all of these behavioral issues that we're talking about. So it's really important for people to know that if you haven't slept well, technically if you haven't slept well most nights of the week for at least three months, which is not very long, you should really talk to your doctor about addressing the sleep problem. And oftentimes sleep solutions are multifactorial, right? We're addressing behaviors, but we're also perhaps using medical therapy or even surgical therapy to get to the root of the problem.

Julia Zumpano:

Dr. Foldvary-Schaefer, would you say seven to nine hours is what's generally recommended for most people, and then also a sign of just waking up feeling rested would be a good sign that you're getting enough sleep?

Dr. Nancy Foldvary Schaefer:

Yes, absolutely. So for middle-aged adults, adults up to the age of 65, the National Sleep Foundation recommends seven to nine hours. That's a wide range and it's a wide range on purpose because sleep needs are genetically driven. Some of us are lucky and we feel wonderful on seven hours of sleep. Probably about 1 or 2% of the population are short sleepers. They really are programmed, their brains are programmed to not need more than four or five hours of sleep. But that's most of us. Most of us who are sleeping four and five hours are just sleep depriving ourselves.

Julia Zumpano:

Yeah, it's definitely not me.

Dr. Nancy Foldvary Schaefer:

Yeah.

Julia Zumpano:

How about with kids?

Dr. Nancy Foldvary Schaefer:

Yeah, kids need more. Kids need more. So babies are spending 50% of their time asleep and half of their sleep time is in REM sleep. So all the physiology of sleep evolves as we get older, but kids and teenagers, depending on their age, may need as much as 12 to 14 hours of sleep. And we know our kids are not getting that. So that sets them up to having these dietary problems as well as many other health issues. Like we mentioned, childhood obesity is a huge epidemic now and it absolutely is tied to these things that we're talking about.

Julia Zumpano:

Yeah.

John Horton:

So when we're looking at the supplements, which we were talking about, I know Dr. Foldvary-Schaefer, you said you have a lot of people come in and they've already started trying these and they start toying around with them. There is a danger in dipping your toe in that pool, right? Because you can almost overdo it in some of these and that causes a whole host of additional problems.

Dr. Nancy Foldvary Schaefer:

You can. I've seen people come to the sleep clinic and they're on 20 milligrams of melatonin. There are a few sleep disorders that are responsive to melatonin. REM sleep behavior disorder, which is a parasomnia can be very responsive to melatonin. But typically not over the dose of 15. And really people who are using melatonin for its slight sedative effect are using one to five milligrams. The problem with melatonin, particularly as we age, I believe, is that we wake up groggy. So these agents can linger in the central nervous system, caffeine can linger in the central nervous system all until the next day basically. So those can have effects on cognition and performance that we really don't think about at all.

John Horton:

So if you overdo it on the melatonin, you're saying you're going to wake up the next day and you're going to be groggy and you don't have that zip that you really want.

Dr. Nancy Foldvary Schaefer:

You may be. And then that's a vicious cycle, right? Because you're sluggish during the day, so you're making these poor choices, not exercising, and it just becomes a cycle, like you mentioned.

Julia Zumpano:

And we were talking about some foods, but increasing your dietary sources of melatonin throughout the day on a consistent basis can help just increase, of course, the amount of melatonin you have in your system, but your body will react and I think ideally make more melatonin if you consistently eat these foods. So we've talked about the tart cherries, the almonds, walnuts, pumpkin seeds, bananas, tomatoes, these are foods that have so many other nutrients, they're nutrient dense foods that they would be great additions to your diet on a regular basis to see if you can up that dietary intake of melatonin to help the sleep.

Dr. Nancy Foldvary Schaefer:

And also I think that people who are using, John, like higher dose of melatonin, very often they've tried everything over the counter too, and they're using a little bit of this over the counter agent that induces drowsiness some nights and using melatonin other nights and using magnesium other nights. And that just leads to a chronic problem of needing to take something to help your sleep without really addressing the root causes.

John Horton:

If somebody is going to take melatonin or magnesium, what kind of limits should they look at putting on those sort of supplements as far as what they're going to take in?

Dr. Nancy Foldvary Schaefer:

So for melatonin, I think really it depends on what kind of effect we're going for. I don't use melatonin that often for sedation. It has a bit of a sedating effect, but it's excellent at advancing sleep in people with circadian rhythm disorders. So it's excellent, we use it for jet lag because it's excellent at realigning people when they've traveled across multiple time zones, can be very helpful for people with shift work when they're off for a few days to kind get a circadian reset with a low dose melatonin. But you'd use that at a low dose, one milligram, maybe not more than three milligrams, and that would be timed differently than right before bedtime. It would be a few hours before your planned bedtime. And then with magnesium, I tend to not use more than around 400 milligrams, but I think I've seen people use more. Julia, what do you think about magnesium dosing?

Julia Zumpano:

I completely agree. I range it between 250 and 500. I use magnesium for multiple reasons. So do help for relaxation, like you mentioned, anxiety, more of that anxious feeling throughout the day, but also it helps with gut regulation. So if you do tend to be a little more constipated, it can also help with that. So I tend to use it in both ways. So depending on what the individual person needs and what they're taking it for, their dosage may vary. But I stick pretty much in that 250 to 500 milligram range. And then the type of magnesium varies too, depending on what they're taking it for as well. So there's magnesium glycinate, magnesium citrate, and there's a lot of different kinds. So I try to help my patients navigate through the different kinds and why they're taking it and help them dose it properly because it's very important to really consider how much you're taking and what kind you're taking. Taking good quality supplements that are third-party tested is also very important.

John Horton:

Yeah, supplements are always... It's a tough game because it's a very unregulated thing. So I know you do want to be careful when doing that.

Looking at the dietary side again, one thing we haven't talked about, I don't think has come up yet, has been tryptophan, which I know we hear about every year on Thanksgiving when we all kind of hit the turkey. Is that something that if you get a little more of that in your diet that it might help you sleep at night?

Julia Zumpano:

Yeah, absolutely. Tryptophan is an amino acid. It does play a role in the production of serotonin, which is a neurotransmitter that affects mood and it affects sleep. So food sources of tryptophan, as we all know, that Thanksgiving turkey, turkey is a good source. Eggs, cheese, milk, seeds, and nuts. So there are several sources. And that could certainly help. Again, these foods are very nutrient dense, so we should be including these foods for other reasons because they provide so many other nutrition sources. So yes, targeting your diet to have more sources of melatonin or tryptophan may help and it also will help other things too, like giving your body enough protein and antioxidants and fiber, so certainly advised.

Dr. Nancy Foldvary Schaefer:

And tryptophan converts to serotonin. And at nighttime, typically around 10:00 PM, serotonin in the pineal gland in the brain is converted to melatonin. So this is a whole axis of important neurotransmitters and amino acids that regulate many things outside of dietary things.

John Horton:

What you're saying is if you eat these sort of foods earlier in the day, it sounds like you almost build up a little reservoir then of these melatonins and serotonins and all this stuff that will help you later on when you finally do have your head hit the pillow and you're ready to go to sleep.

Julia Zumpano:

Yeah, I think it's just providing adequate nutrition throughout the day and providing these sources of foods that will help, the amino acids and the melatonin and the magnesium and all these foods that will put the whole picture together into improving your overall health, decreasing inflammation. If we eat whole foods, we're more likely to be able to manage our weight. And then of course that all plays a role in the sleep.

Dr. Nancy Foldvary Schaefer:

And our brains will signal melatonin secretion at night and that melatonin secretion is one of the driving factors to make us sleepy. There are people who are night owls, it's sort of the night owl syndrome, delayed sleep phase disorder, very common to emergent teens and then continue out through life, who don't have enough melatonin secretion. And this is why their melatonin curve is sort of sluggish, it's blunted and it's delayed, and so they don't get that signal to feel sleepy until hours later and that leads to a host of additional adverse outcomes.

John Horton:

It's just amazing how the human body does all of this stuff. So as we're running through these foods though again, there were two that were on the list that were really kind of my favorites. They both made me smile because it kind of brings you right back to childhood and everything, and that was chamomile tea and warm milk. So do they do anything to help you fall asleep?

Julia Zumpano:

Well, chamomile tea is very calming, it's very relaxing. It does tend to just relax your whole system. So I do feel that people have reported a lot of benefit with just feeling more relaxed with chamomile tea. Now you drink that in the right setting of a dim room and a comfy bed and you are ready for bed, I mean, that's probably going to end up really helping you get to sleep. The hot milk, hot milk can help really too. With little kids, with my kids, I give them some hot milk and honey because honey can actually have a small amount of melatonin, as can milk. Again, any warm liquid, that doesn't have caffeine of course, can help calm and relax the system. So those can certainly be helpful. They're harmless in any way because of course they're providing other forms of nutrition. So I do often recommend some sleepy time type teas in the evenings that are mainly based with melatonin.

John Horton:

And definitely do those a little bit before you go to bed, right? Because then if you do it right before, that sometimes can lead to that middle of the night trip to the restroom.

Julia Zumpano:

Yeah, yeah. And of course, depending on how much honey you're putting in the milk and honey, just a teeny tiny bit, you don't need a lot. Just a four to eight ounce glass is all you really need. And again, yeah, if you struggle with waking up in the middle of the night, making sure you're doing that, let's say, an hour to 30 minutes before bed for sure.

John Horton:

Well, I think we've done a really nice job of tackling all the food that we should be eating to maybe lead to better sleep. Now let's look at some of the things you might be putting down that could cause problems. I already mentioned those extra spicy chicken wings a little late, but what other things maybe should people be avoiding if they want to have just a really restful night in bed?

Julia Zumpano:

Well, spicy chicken wings, for obvious reasons, we have the spice. Spicy foods can really affect your digestion and cause reflux for some people. They're very high in fat, so we want to avoid very fatty foods. Fatty foods take the longest to digest in our guts, so can really have that upset heavy feeling in your stomach. Again, fatty foods that are spicy are going to sit in your stomach longer and then be more opt to create that reflux reaction. So other than spicy chicken wings, you want to think of spicy snacky foods like chips or spiced popcorn or snack foods that you might be snacking on at night.

And then as we mentioned throughout the podcast is sugary foods. So avoiding snacking on candy or chocolate. Chocolate actually has caffeine in it, so the darker the chocolate, the more caffeine it's going to contain. Although dark chocolate is a phenomenal source of antioxidants, we really want to have that throughout the daylight hours before dinner and try to really calm down any intake after dinner. So avoiding caffeine of course, so like coffee, chocolate, caffeinated teas, any energy drinks or sports drink that might have caffeine. Alcohol is another one that can really disrupt sleep. So we really want to minimize or avoid alcohol as much as possible. The fatty and the sugary foods are the main ones.

Anything else to add, Dr. Foldvary-Schaefer?

Dr. Nancy Foldvary Schaefer:

I think alcohol is a really important one to mention because it's probably the most common thing American adults reach for to help fall asleep at night. It's a great sedative, but when it metabolizes after a couple of hours, it leads to fragmented sleep, more wake time in bed and very importantly, suppresses REM sleep. And we need REM sleep for brain health. And so regular alcohol use will definitely harm our brain's ability to do what it needs to do when we sleep and protect every cell in our body and restore every cell in our body.

Julia Zumpano:

A lot of times that alcohol can be habitual. So oftentimes that's where I might recommend a sleepy cocktail in response to, "Well, instead of your glass of wine, let's try to do a glass of hot chamomile tea." Or maybe, like we mentioned before, a little bit of the tart cherry juice with a little kombucha or there's some magnesium powders that you could have with some water. So something to replace that habit if you're used to having something to sip on. But utilizing that habit as creating a positive choice that may actually help promote sleep and good sleep throughout the evening.

Dr. Nancy Foldvary Schaefer:

And caffeine, I just mentioned caffeine again. Caffeine has highly variable half-life, there's genetic influences there, certainly age-related influences. There may be other kinds of influences. But many people feel that they can drink coffee or other caffeinated drinks or caffeinated foods, like their dark chocolate at night and even small amounts of caffeine can be disruptive to sleep.

John Horton:

Well, I know we'd mentioned alcohol, and if anyone's interested in learning more about that, we did an entire Health Essentials podcast on that with Dr. Foldvary-Schaefer just a little bit ago. So go into the list and go find that and you'll hear some fascinating stuff.

So I think we covered that list really, really well with all the things. I have a lot I need to work on is what I just learned from everything you guys said. But given that one out of three people don't get enough sleep, I'm guessing that this discussion might help a lot of folks who are listening. Dr. Foldvary-Schaefer, how common is it that people can maybe resolve sleep problems through just basic dietary changes?

Dr. Nancy Foldvary Schaefer:

Well, I don't know that it's so common to just make a few dietary changes and fix a significant situation of sleep deprivation. But again, I think when we make healthy choices, we tend to begin making other healthy choices. And there are so many fairly simple things to do that can help lengthen sleep and provide those deeper stages of sleep. One being just anchoring your wake-up time. Anchoring your wake-up time every day and not letting that be wildly different on days off or weekends is going to drive that regulation of the circadian rhythm and it's going to make it easier to fall asleep close to the same time every night. We don't want that variability. And then removing alcohol and caffeine and heavy meals, exercise near bedtime, all of these things really work very well to help promoting better quality sleep.

John Horton:

And that's where you realize diet, I mean, sleep is so multifactorial, so diet can be a key piece of that, but it's not acting alone. So it sounds like all these things that you've talked about on this podcast so many times, sleep hygiene I know you've walked us through the best practices you can do as far as putting down your electronic devices an hour or so or two hours before bed. And just making these sort of choices can really help in combination.

Now, when we were talking earlier, you said Cleveland Clinic has an app that people can go to to maybe even help them unlock the mysteries of why they might not be getting enough rest.

Dr. Nancy Foldvary Schaefer:

Yes, we've got a mobile application called Sleep by Cleveland Clinic. It's available now on iOS and Android platforms. And the purpose of this is to provide basic education to adults. And it provides surveys for the four most common sleep problems probably worldwide, certainly in the United States. Those are obstructive sleep apnea, insomnia, insufficient sleep, which we quantify by estimating how much we sleep and how much we sleep during the day as well, and then shift work sleep disorder. So for people who are shift workers, some of them actually do just fine and do not have symptoms of a sleep disorder during their wake hours, but most of them have problems functioning during their wake hours because of the timing of their sleep. So the app will provide scores for these things and then allow the user to kind of click for what's next and read a little bit about what problem they might have, and then also identify a nearby accredited sleep program.

So it gives people an opportunity to screen themselves, which I think is really important because our primary care providers are often very busy. We often have many things we want to review when we're in our annual primary care visit, and sleep is often not at the top of the list. And it's also important to recognize that many physicians and advanced practice providers unfortunately haven't gotten a lot of sleep education in their training programs. It's just something that we don't hear enough about. So I think it's important for people with sleep problems that persist after a couple of months to make it a priority to mention this to your primary healthcare provider. And you may also need to visit a sleep expert.

John Horton:

Yeah, it's definitely not something to mess around with. If you're not sleeping well at night, it is going to roll into just every aspect of your life and it's something people do need to pay attention to. And you've made that clear so many times on here. And I know all the little tips you give, they're so helpful.

So Dr. Foldvary-Schaefer, every time you're on, I feel like we have a conversation that just can work wonders for people and really crack that code as to why they're having trouble sleeping and how they can get some help. So kind of before we depart here today and everyone goes off hoping to find dreamland, I'd love for you and Julia to share something you want folks to take away from today's podcast as they look to just sleep a little better.

Dr. Nancy Foldvary Schaefer:

For me, it's sleep is critically important. It's foundational to health and wellness, and it goes hand in hand with a good diet and hand in hand with good exercise. We spend so much time and effort and money promoting and utilizing good diets and supplements and various things that help promote good nutrition, as well as exercise equipment and health clubs and all of that. But relatively much less time thinking about good sleep. So it's important to just remember every day that sleep is just critically important to your health.

John Horton:

We spend a third of our life sleeping, so you should pay attention to it, right?

Dr. Nancy Foldvary Schaefer:

We should be spending a third of our life sleeping.

Julia Zumpano:

Yeah, I couldn't agree more. Every patient I have, I ask them about sleep, exercise, and of course nutrition. But I do spend a good quality amount of time discussing their sleep habits because I can't say enough about how much that can influence my nutrition goals for them. So if I'm really trying to help them lose weight or reduce their inflammation or whatever it might be, and they're not sleeping enough and they're stressed, it's not working, my plan's not going to work if they're not sleeping enough. So I think it's essential, and I think Dr. Foldvary-Schaefer said it perfectly is that it's essential to health and you really need to look at all three, the exercise, the nutrition, and the sleep. They're all equally as important, and I think we really need to focus on what we're eating throughout the day that could be affecting our sleep. So really just screening through your day and seeing if there are some of those triggers that could be negatively impacting your sleep or any habits that you're doing that could be negatively impacting it.

John Horton:

Well, sleep and diet are definitely two pillars of a healthy lifestyle, and the two of you are just basically two pillars of this podcast. So I appreciate both of you making some time to come in here today and just share so much great information that I really think can help people get the answers that they need and hopefully get a good night's sleep.

Dr. Nancy Foldvary Schaefer:

Thanks for having me.

Julia Zumpano:

Yeah, thank you so much.

John Horton:

As you just heard, diet and the quality of your sleep are closely connected. So if you're not sleeping well at night, and the research shows that's probably true for a lot of folks who are listening, it might be time to reassess your eating habits. The changes you make might improve your rest at night, so you can function better all day long. If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, eat well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.