Disease or hormone imbalance?
I have been plagued by insomnia for years and years. I have attributed it to many things and have been diagnosed with a variety of “disease states”. Depression is associated with insomnia, check. Too much stress from the loss of loved ones to the stresses of medical school and residency, check. The perils and pitfalls of perimenopause and menopause, check. But, I have discovered a new one that gets barely a mention and is thought to be inconsequential by most physicians, and I believe it may be contributing to the legions of people suffering from insomnia in our society. This is the complex biology of blood sugar regulation.
Blood sugar and cortisol
For the last several years, I have suffered from that 2-3 AM awakening, and am unable to go back to sleep. In fact, it has actually gotten worse over the years, but is inconsistent with periods of severe insomnia, awakening with a pounding heart and a feeling of anxiety and sweating. My hormones are perfectly balanced, I eat an organic diet and I exercise, so why can’t I SLEEP?! I have asked my professors and colleagues and have gotten many theories and suggestions but nothing has worked. One night as I struggled with a sweaty attack and pounding heart, I got up to go the bathroom and decided to check my blood sugar – 75. I went back to bed (I confess after taking GABA supplement to try to get back to sleep), and the next morning, again took my blood sugar – 95. Hmmmm, why would my blood sugar go up in a fasting state? Well, this has to do with poorly functioning hypothalamic-pituitary-adrenal axis, and what we in functional medicine know as adrenal fatigue or adrenal dysfunction. This is thought to be a very common thing in our stressed, overworked, burned-out society. Cortisol, which is produced by the adrenal glands, is your stress hormone and one of its jobs is to maintain your glucose levels so that your brain, heart and muscles have a continuous supply of glucose to create energy for these vital organs. Cortisol is essential to life and your body will defer to making cortisol when stressed as evolutionarily, this can save your life. Your body does not know or care WHY you stressed. The flu, surgery, running a marathon, starvation, or a crummy, demanding job; it’s all the same to the body and it pours out cortisol for your survival.
Burnout
With excess demand over the years, your adrenals falter and misfire, the signals are erratic and along with many other symptoms (fatigue, apathy, depression), your blood sugar can get too low or too high because of erratic cortisol. During the night, when you are in a fasting state, the adrenals will slowly secrete cortisol to maintain your glucose, and the peak cortisol usually occurs shortly after arising in the morning. However, if your adrenals are a little off, or your blood sugar gets too low, the adrenals can overshoot and your cortisol will increase too early (2-3 am) to make sure your blood sugar is maintained. Thus, you get symptoms of hypoglycemia, followed by a cortisol surge accompanied by an increase in epinephrine and norepinephrine resulting in sweating, a pounding heart, and an anxious alertness. I might add that falling estradiol associated with menopause is a contributing factor and can make these symptoms even worse, but that is another post.
What can you do?
Our highly processed Standard American Diet (SAD) is very high in simple carbohydrates, which is contributing to our epidemic of insomnia.
I have discovered that if I carefully follow a low glycemic diet (nothing above 60 with a glycemic load <10), I sleep much better. No more ice cream, chocolate, or even fruit especially at night. A high protein breakfast (eggs and spinach) begins the day, with each meal containing at least 20-30 grams of protein. I avoid most grains. I am not
photo courtesy of PlanetChopStick under Creative Commons
saying that whole grains are not good for you, but if you have blood sugar issues, you probably want to make grains a rare treat. Avoid fruits with high sugar content and opt for those that are more tart and loaded with fiber like raspberries. At night, I have added a protein drink from Metagenics called Perfect Protein. It has 16 grams of whey protein and only 80 calories. This has become my nighttime desert. If I watch my sugar intake and take this at bedtime, I am much more likely to get a night of blissful, uninterrupted sleep. Maybe there is something to the old adage that a glass of milk will help you sleep. With a few modifications, it seems to be working for me. Happy snoozing! ZZZZZzzzzzzz
NB: At posting time, my favorite site to check glycemic load is down – for more information, try here.
Marsha Nunley, MD 
Sometimes a snack of 1 carbohydrate and 1 protein before bed can help carry you through the night without issue. Sounds like your shake covers that and helps you sleep!
In a fasted state, your liver can release blood sugar that it stores up if it:
A. Needs it (if you didn’t eat enough carbohydrate at dinner or if you ate many hours before bed) – this is where the snack helps.
OR
B. is participating in “The dawn phenomenon” where hormonal changes at that time of the night/morning can tell the liver to kick out blood sugar.
Your article makes so much sense and reassures me that there are natural ways to promote sleep. I have been a great sleeper all my life and the insomnia I’ve had the past 3 months has cause me great concern. I recently had blood work done and will see you in January!
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Wow! I have figured this out as well. Sooooo grateful to have found your site. I found information a few months ago that suggested that sugar competes with the neurotransmitters that aid sleep …and sugar wins out every time. My path has been so confusing for so many reasons with almost unbearable symptoms. This past summer was the worst with wakings every hour or so. No restful sleep for months. I literally thought I was going crazy. Slowly I have changed my diet and have seen improvements. The holidays had me indulging only a bit and even small amounts of sugar disturbed my sleep. I also have thrush and am trying to combat candidasis( sp?). I look forward to exploring your site !!!! Thanks so much. So comforting to know there are others going through similar struggles.
Yes, after talking to dozens of colleagues both alternative and traditional, I basically figured this out by trial and error. And you are right, “sugar wins everytime”. Getting off sugar will help your thrush as well. It is a process with many ups and downs so be patient and kind to yourself.
Thank you for the encouraging words! The thrush is slowly going away as well. I wish more people with sleep issues knew about this . I even went to one of the best sleep Drs in Nashville this summer and he was stumped. He offered meds but I knew that would convolute the matter. So grateful the Bay Area has someone like you to hopefully help spread the word! All the best!
When a new post becomes available or in cases where any changes happen on your site, I would love to read more and finding out how to make good usage of those approaches you discuss.
Progesterone may be prescribed if a woman has a normal menstrual cycle and then stops having periods. During pregnancy, particularly during the first trimester, Progesterone…progesterone
I’m a little confused…if your blood sugar is too low, then the cortosol will be excreted, so if we eat “low sugar” foods, wouldn’t that cause us to go into hypoglycemia from cortisol surge, waking up with heart pounding and the sweats? In other words, by keeping our sugar intake on the high side prior to bed, wouldn’t that keep the cortisol away? I don’t think you make any mention of insulin secretion in the equation. Thank you!
Sorry for the confusion, Stephanie. The worst thing you can do is keep your sugar “on the high side”. What happens is that the high glycemic food ie rice, pasta, white potatoes, and sugar, cause a brisk insulin response which rapidly lowers your blood sugar. The brain and heart, possibly the two most vital organs in the body are particularly dependent on glucose so the body will not allow glucose to decline. Mechanisms are set in place that cause the adrenals to secrete cortisol, epinephrine, norepinephrine which brings the blood sugar back up but this response can cause symptoms such as sweating, racing heart, and anxiety. The sugar insulin response is essential to life but the pancreas and adrenals have to work overtime with the high sugar loads that are in our diets today. A fasting blood sugar higher than 86 is associated with increased risk for cardiovascular disease. A chronically elevated blood sugar is associated with aging in general and increased risk for many chronic diseases. I frequently have my patients monitor their blood sugar with a home glucose monitor. It helps to understand how what we eat effects our blood sugar. You might want to try cutting out all processed food, refined sugars, and eat things that are low on the glycemic index and see how you feel. Hope this helps.
Thank you for explaining. What really bothers me, is that the FDA approves life-threatening levels of fat, sugar, and sodium, and then they also approve medications for conditions brought about by these long-acting “poisons”. They’re in everything we eat. It’s such a contradiction, and very scary.
Hi again–For example, I just read on a yogurt conainer–6 oz.–that there are 18 grams of sugar!! Is that a lot? How many grams of sugar a day, and at one meal, are healthy for an average person to eat? Thanks so much for explaining…
I am not sure I understand your argument. If you have a glycemic dinner at 7 pm, wouldn’t the insulin surge and the resulting hypoglycemia l occur long before 2-3 am? Also, if hypoglycemia is waking you up at 3 am, wouldn’t eating a snack with complex carb at 3 am help with falling back to sleep. Finally, is there any peer reviewed papers that show that people who wake up at 2-3 am actually suffer from hypoglycemia?
I think the blood sugar issues have more to do with adrenal dysfunction. Certainly stress plays a role in sleep. The problems with anxiety and sleeplessness seem to be compounded by a diet high in carbohydrates. I have found that a high cortisol or a high blood sugar or a low blood sugar can cause sleep issues. (as well as other issues) It seems to be more related to an instability in blood sugar rather than just high or low. The high protein, low carbohydrate diet seems to level this out. No peer reviewed studies on this phenomenon. Most papers assume that insomnia is related to an underlying process such as depression and recommend drug therapy. Most sleeping medications interfere with normal sleep architecture and should not be recommended long term. I have found the dietary changes to be helpful and think that it is a pretty benign thing to try. A complex issue with many etiologies and would love to see some studies on this but I doubt that is going to happen.
The sugar in the yogurt comes from the fruit and flavorings that they use. I would suggest plain yogurt and use fresh fruit like apples for sweetening. Ye, 18 grams is a lot of sugar. And remember, look at the amount of carbohydrate because that is the true amount of sugar. A serving of plain yogurt contains about 4-6 grams of carbohydrate. Get your sugar from whole foods and you won’t need to count. Treat fruit as a dessert. Keep whole grains to 1 serving a day and none if you are trying to lose weight or have blood sugar issues. Stay away from all food that comes in a package or box. For weight loss, I put people on 20 grams of carbohydrate a day (plus some supplements).
Regarding the FDA, unfortunately I think the FDA is more concerned with protecting profits than consumers. They are funded by the entities that they are supposed to oversee. Watch this movie, http://www.burzynskimovie.com/
for some revealing insights about how the FDA works.
Thank you! I guess I’m making you work! My yougurt container says this: Sugars: 18g, Total Carbohydrate 21g. So are you saying that this yogurt actually has 21g of sugar, or that it is to be counted as much? For a person who does not have blood sugar issues, what is the safe range of sugar/carbohydrate grams per day? thank you for the website I will look at to tonight. And thank you for helping us be more healthy.
Snicerely, Stephanie
Thanks for this article! I have had occasional issues with heart-pounding anxiety-filled insomnia over the past 6 months. Ironically, my first episode was last Christmas eve (when you wrote this?). I had eaten the plate of cookies left for Santa! After several episodes over the next few weeks (thought I was losing my mind) I stumbled across another web source suggesting hypoglycemia as the cause. I started to notice a pattern where the episodes did seem to be triggered by what I had eaten. A dinner of Chinese food (with rice) combined with a few drinks appears to be a recipe for disaster in the middle of the night. I have had reactive-hypoglycemia for years, but I skip simple sugars, snack frequently, and usually don’t have too much trouble with it. Lately, though it seems to be much worse – maybe due to getting older, or increased stress. I have found that If I can eat a little bit of cheese before bed, that seems to help. I’m still figuring out what works and what doesn’t for the insomnia. This article is a big help!
I am glad you found it helpful. I find that the insomnia can fluctuate not only with sugar but as you have noticed with stress and aging. As we age cortisol goes up and we have more trouble maintaining a stable blood sugar. The cheese or a spoonful of your favorite nut butter is helpful because it seems to help stabilize your blood sugar.
Thank you very much for the article. I have already started following your advice. And I am getting better with my sleep.
You say: “At night, I have added a protein drink …”.
How long before the bed time it is recommended to have the drink?
Sincerely,
-Mike
Hi Mike,
I find that if I drink it right before bed, I feel a little full so I would say about 30-45 min before bed. Glad it is helping.
In health,
I noticed the following info at: http://www.answerfitness.com/335/take-protein-before-bed/:
“Casein protein is the what you’ll hear bodybuilders typically recommend as a good protein to take before bed.
Casein is one of two primary proteins in milk (whey is the other.) While whey is admired because it is rapidly digested in the body — making it ideal for a post-workout recovery drink — casein is the exact opposite.
When casein protein hits the stomach it curdles — slowing down the bio-availability of the amino acids. Eventually, your body will digest the majority of the proteins in casein, but it takes time — between 6-8 hours.
While this wouldn’t be optimal immediately following a workout, it’s ideal before bed. Think of casein as an overnight “protein drip” when you are in bed.”
Would you recommend Casein protein instead of Perfect Protein (it has 16 grams of whey protein)?
Hi Mike,
I don’t generally recommend casein as many people do not tolerate it. It has morphine like metabolites (guess could be beneficial at bedtime)and can be a culprit in food intolerance (autism and neurological and mental disturbance) for many people. Honestly, in my circles, have not seen anyone recommend casein, but if you don’t have a problem with it, give it a try at night. I like the thought of the slow absorption and lasting through out the night.
In health,
Hi Dr. Marsha Nunley,
Thank you again for your promptly replies.
For how long (months or years) would you recommend to follow this diet?
Sincerely,
-Mike
As long as it works for you. It is healthy and works long term. If you go off and start having problems, just resume.
In health,
Dr. Nunley: Your write up was the story of my life…exact problem! I have been on the Paleo/Gluten free diet for about 6 months now at least….every now and then we have a gluten meal when we go out. I still was having a problem. I noticed lately that sugar makes me very hyper….friends came we ate out 3 nights in a row with delicious deserts….I didn’t sleep for 3 nights! I realize sugar is the culprit…today I am experimenting to see if I can have dark chocolate before noon and still sleep by 10. I am also experimenting to see if I can have a few beers earlier in the day and still sleep ( I have to have some vices to feel human I guess). I drink a almond butter/spinach/almond milk fruit drink in a.m.
I think is what’s going on with me!!
I can’t agree more. I just discovered this recently (by accident). I steeply reduced my carb intake for weight loss / calorie restriction and within ~48 my sleep improved dramatically after 10 years of increasing insomnia, middle of the night wake-ups etc. No one ever provided me advice to this effect. More people should know about it. Thanks for writing about it. Greg.
Hi there, interesting article… My insomnia started 3 months ago, for a period of a week I couldn’t fall asleep due to what is seems adrenaline rushes that would occur just as I am about to drift off to sleep. Now, 3 months later its gotten so much worse, I cannot fall asleep for hours, wake up every hour or so and sometimes wake up at 5 or 6 and unable to fall asleep again. The worst thing is that I am constantly wired, I cannot take naps at all, and even if I sleep for 2 or 3 hours the night before, I am still not feeling sleepy or tired to force myself to sleep. Do you think this could be the problem? I am a 24 year old, physically active male. Thanks
Sugar could certainly be a contributing factor. I also think an unhealthy gut and food sensitivities resulting in a histamine response could be contributing to your symptoms. See a doctor familiar with this. Someone in functional medicine is your best bet.
In health,
Marsha Nunley, MD
Hi Dr. Marsha.
Periodically bad thoughts are chasing me and I am getting stressed which in turn disturbs my sleep. I am taking one or two tablets of Lorazepam 0.5 MG which calms me down and I can sleep.
I am in this state for about one year. What do you think about long-term usage of Lorazepam?
Your reply is greatly appreciated.
Sincerely,
-Mike
Finally, an explanation for my sleep pattern that makes sense to me.
However this is my ‘back-to-sleep’ ‘medicine’. LOL.
A hot fudge sundae on French vanilla ice cream. Both high quality brands with few additives.
Works like a charm for a couple of decades now.
This is about the only time I eat ice cream.
Get a good probiotic and digestive enzyme and make sure your sinus cavities are clear….all of this helped me sleep better…..also cutting ou5 coffee and going to a mild tea. I feel that some people, like me, are wired for activity and stimulation…..we must physically work and mentally work to stay clear of bed time activity. I also cut out negative people to a great degree.
What is your opinion of taking a plant-based protein drink before bed instead of a whey-based protein drink? The one I have has 19g of protein, 110 calories, protein blend (pea, hep, flaxseed, brown rice, chia seed). Thank you!
I think your shake is as good as the whey protein. Even though supposedly whey is the highest quality protein, your plant based protein should be a good option. Fluctuating blood sugar is the problem so I don’t think the form of protein matters.
In health,
Dr. Nunley
I tried Trazadone for sleep….kept me up all night!! It works like a charm on my husband. I tried an antidepressant & that kept me wired….
I want to thank you for this post.
I was totally mystified as to why I wasn’t sleeping and then I had a hypoglycemic episode one day. With further research I happened upon this article and it resonated with me.
Thank you for taking the time to research this, write this, and to put the power back in my hands. I always look for natural cures and I am so happy to know that with a slight change in my diet, I can manage this and thrive.
Sincerely,
Abbey