As practitioners, we know well how critically important adequate sleep is to our health. It’s essential to the healing process. Insufficient or disturbed sleep can slow recovery, compromise our immune function, increase inflammation, impair judgment and cognitive ability, and speed up the aging process, just to name a few negative outcomes.
Broadly speaking, sleep dysfunction comes in two flavors: those who struggle getting to sleep and those who fall asleep easily, but can’t stay asleep. Then there’s a hybrid of the two: those who can’t fall asleep OR stay asleep… Ouch.
Sleep is the darling of bio-hackers and functional practitioners of all stripes. There are many different things to consider, from proper sleep hygiene, stress management, exercise habits, to basic dietary strategies. These are always the places we address first, but what if they don’t work? What if you’ve addressed all of these fundamentals and you or your client is still struggling with sleep?
Time to bring out the functional testing! There are some key underlying physiological imbalances that can profoundly affect our sleep, and as functional health professionals it’s our job to ensure we’re investigating these areas for those clients who struggle with sleep.
1. Blood Sugar Imbalances
The first and most common type of sleep issue is poor blood sugar regulation. Specifically, a blood sugar crash in the middle of the night. When blood sugar levels dip too low and if the liver isn’t able to mobilize glycogen stores quickly enough, the adrenal glands will come to the rescue, secreting a rush of the hormones cortisol, adrenaline and noradrenaline to essentially force glycogen into the blood. These hormones are all very stimulating and thus can rouse one from sleep and then keep them up.
One very basic strategy for handling this night-waking is to eat a small protein-based snack before bed. If it resolves night-waking then it’s likely that low blood sugar levels are the culprit. But eating that snack doesn’t resolve the hypoglycemia itself – it’s simply a band-aid. Ultimately, we want to support and address the client’s hypoglycemia such that these middle-of-the-night crashes that require a nightly snack in the first place.
How do you identify whether it’s a blood sugar crash that’s causing the night waking? The first place to look is a fasting blood glucose test on waking, which will let you know what that morning glucose looks like, as well as looking at the client’s lactate dehydrogenase (LD), a serum marker that will be functionally depressed with reactive hypoglycemia. If the culprit is indeed hypoglycemia, then we address the glycemic imbalance with dietary adjustments and appropriate supplementation (something we teach in Level 3: Mastering the Art and Science of Nutritional Blood Chemistry).
2. Hypothalamus-Pituitary-Adrenal Axis dysregulation
Another common culprit for night wakings and a close companion to blood sugar dysregulation is Hypothalamus-Pituitary-Adrenal (HPA) Axis dysregulation, which is a breakdown somewhere in the chain of command between the hypothalamus, the pituitary and the adrenals. This can interrupt the body’s natural circadian rhythm and cause night wakings. The only way to know if this is a factor is to do either salivary or dried urine adrenal hormone testing (something we teach in Level 2: Mastering the Art and Science of Optimizing Hormones), and then support the imbalances via appropriate dietary, supplementation and lifestyle interventions.
3. Hormone dysregulation
Another close companion to both blood sugar dysregulation and HPA axis dysregulation is sex hormone dysregulation. This is because blood sugar dysregulation will negatively impact the HPA axis, and adrenal dysregulation impacts the whole endocrine system. So think of these as three amigos working hand-in-hand.
As any symptomatic post-menopausal woman will tell you, hormones (or the lack thereof) can wreak havoc on one’s sleep – both falling and staying asleep. But hormonally-driven sleep issues aren’t relegated to post-menopausal women. In men, low testosterone can compromise sleep, and in cycling women, low progesterone can do the same. Now, once again, the best way to understand how hormones are affecting sleep is to test, and we strongly recommend never manipulating hormones based on symptom presentation alone, as hormones are a two-partner dance: the imbalance can be in the amount of a hormone produced OR it can be in the inability of the cell receptor to receive that hormone. Thus one can display the symptoms of a lack of a given hormone in the presence of an excess of this hormone. This is a hard but important concept to grasp and we dive into this in depth in our Level 2: Mastering the Art and Science of Optimizing Hormone.
4. Immune activation
The fourth possibility is immune activation. We know that the immune system does the bulk of its work at night and this can have a stimulating effect. Consider that one of cortisol’s many roles is as an anti-inflammatory agent – if there’s inflammation, which is a process of the immune system, then cortisol will engage to anti-inflame, which can be stimulating. If you are trained in working with blood chemistries, you can get a sense of whether immune activation is a piece of your client’s puzzle by looking at their white blood cell levels and differential. Also, don’t forget that any gut infection will cause this kind of immune activity, and is one of the most common reasons the immune system is engaged, so by starting with the gut as we always advise, you’re necessarily addressing this piece at least in part.
5. Gut health
Speaking of gut health, there is fascinating research  showing that our intestinal microbes have their own circadian rhythms. When our microbiome is out of balance, it can affect our overall circadian rhythm. Discomfort from GERD (gastro-esophageal reflux disease), especially when triggered by late-night snacking, can disrupt sleep, especially in the early parts of the evening, as the symptoms are exacerbated by lying down. Also, parasites and the bruxism (teeth grinding) they potentially cause can also be an underlying contributor to sleep disturbances.
6. Vitamin D deficiency
Lastly, there’s new research  that has connected vitamin D deficiency to difficulty with sleeping – both falling asleep and staying asleep – and so testing your client’s vitamin D levels and ensuring sufficiency is a relatively easy and doable strategy for all your clients.
Clinically what all of this means is that when you’re supporting a client who struggles with sleep, not only should you consider their sleep hygiene and basic dietary strategies, but you also want to do some deeper digging to determine if any of these physiological factors can be contributing to the situation.