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Light, activity and meals are key inputs to the circadian rhythm. These tools can be used to help manage the circadian rhythm to get it working better for you and optimise your health.
00:00 – 00:35 Tools for managing circadian rhythms
- 00:35 – 02:42 Using morning light and managing evening light
- 02:42 – 03:14 Physical activity and meals
- 03:14 – 04:11 Delayed sleep-wake phase disorder
- 04:11 – 05:15 Irregular sleep-wake rhythm disorder
- 05:15 – 06:40 Entraining the circadian rhythm
- 06:40 – 08:07 Advancing the circadian rhythm
- 08:07 – 09:46 How quickly can you shift?
- 09:46 – 12:23 Examples
- 12:23 – 13:05 Summary
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What are the things that can be done to help manage the circadian rhythm and get it working better?
The key inputs to the circadian rhythm and tools that we use to synchronise the circadian rhythm are light and that can be light exposure in the morning, managing light exposure in the evening to minimise it, using melatonin to reinforce that dark signal, physical activity and movement, particularly first thing in the morning and timing and regularity of meals.
To get the rhythm working best, we need to manage all of these things and get them in a regular type of routine. So that routine starting in the evening is really once the sun has gone down outside, essentially it’s dark. So if we weren’t in a modern industrialised sort of world, the input we would be giving to our brains is there’s no light, therefore the time for sleep is coming near.
So that’s the time to be very cautious about light in our modern environment and if there is light, particularly the computer screens, tablets, and you’re having trouble with getting off to sleep, then managing that light. That’s where blue blocking glasses come in to really block that blue wavelength light, which is the key light for delaying the circadian rhythm or inhibiting the onset of sleep with the circadian rhythm and the onset of the production of melatonin that occurs with darkness.
So there are the glasses that you can use that block the blue wavelength of light or if you’re using computers and tablets, there’s apps such as F.lux which can block the blue wavelength light in both computers and tablets and smartphones.
Then in the morning at the time that you are normally getting up and the body is sort of ready to get going, that’s the time when we want light. So rather than blocking light, like the evening, we want to be giving the body that signal much as we would be if we are sleeping in a cave or sleeping outside. The sun comes up. We get that bright signal. We want to be giving the body that signal. Hey, sun is up. Daytime, time to get going.
Now if it’s light outside at the time we’re doing that, then outside is best because outside light really is pretty easy and that’s the best way of cueing in the body clock.
But if it’s dark outside at the time we need to get going, then we can use a blue wavelength light. So there are a number of devices that are available for doing that. I’ve got a blog post that I will put a link to at the bottom of this video post about the different light sources. But it can be something like the Re-Timer glasses which have a blue-green wavelength light, goLITE BLU which is a blue wavelength LED and there are a number of other products that you can use as bright light treatment sources.
In terms of physical activity, first thing in the morning, just movement seems to feed into the central clock. There’s a suprachiasmatic nucleus that controls the circadian rhythm and give a cue again that it’s morning time, time to get going.
Regularity of meals is really important. So the time we eat meals does cue in the peripheral clocks, so in the liver and the gastrointestinal system and they in turn feedback to the central clock, an act of synchronising signals to the central clock. So having regular meals is a key part of keeping a regular circadian rhythm.
Now the two common problems I see with the circadian rhythm, where I will usually in my clinical practice be working on trying to manipulate the circadian rhythm to get it back on track, are delayed sleep-wake phase disorder and where there’s a reduced amplitude rhythm or it can be called an irregular sleep-wake rhythm disorder.
Delayed sleep-wake disorder is where there’s an offset between the time people desire to go to bed and get up and their intrinsic body clock. The most common example is adolescents where they desire to go to bed for example – parents desire them to go to bed for example at 10:00 PM and up at 7:00 AM for school but they may not be ready for sleep until 1:00 or 2:00 AM and not ready to get up until 10:00 or 11:00 AM. So there’s an offset in terms of that time or a phase delay is the terminology we use.
If that’s the problem, I would be looking not just at getting a regular rhythm but we’ve actually got to push the rhythm back. We call that “phase advancement”.
The other common problem I see with the circadian rhythm is in people who have got physical illness, mental illness, had a range of other medical conditions, they just get this irregular sleep-wake rhythm disorder. Not a strong sense of, “I’m alert at any particular time. I’m tired at any particular time.” Things just don’t seem to be operating with a regular routine.
So what we want to do in that problem is what we call “entrain the circadian rhythm”. Give really strong external cues to the circadian system so that it goes from a flat out amplitude type of rhythm, so it’s not giving that strong alerting signal and that strong sleep signal to a much stronger signal that as people get that sense, “Oh, I do feel sleepy come this time in the evening and in the morning I do feel like I’m actually getting going in the morning rather than feeling sluggish across the day.”
For a lot of people I see, they’ve actually got a bit of both. They’ve got a poor entrainment or a sort of a flatter low amplitude circadian rhythm and some phase delay.
I will generally approach it in a stepwise sort of manner. The first step will be aiming for entrainment, getting a regular routine. Part of that just gets people used to using the tools that we use like melatonin activity, regular meals, but it’s also important in getting the body into that regular routine, that bit of entrainment to then you get a sense or a confidence in using the tools and a sense that, right, things are now on track.
So this slide shows my regular sort of recipe for entraining the circadian rhythm. So I will look at using light and activity on arising in the morning and melatonin and controlling light in the evening. In general I prefer to have melatonin 12 hours before the waking time in the morning and roughly about four hours before the time, desired time of going to sleep, which then leaves around eight hours for sleep, and then the light exposure for 20 to 30 minutes as soon as possible after arising in the morning.
Now whilst that’s the ideal time for melatonin because that’s when the body clock is the most sensitive to melatonin, some people are quite susceptible to the sedative effect of melatonin. So if they’re taking it four hours before bed, they feel a bit too dopey in those four hours. So they’re not compromised and shifted a bit closer to bedtime, even as close as an hour before bedtime. But I try to have it as far away from bedtime as they can tolerate without getting too susceptible to that – you know, I’m just feeling dopey.
Once someone has got a nicely-entrained pattern and confident in using those tools, then I can move on to the next, which is looking at advancing their circadian phase. That’s when we try to shift the phase of where their sleep is occurring by shifting those cues or inputs of light and melatonin so that we can either shift their phase earlier in the example of the teenager who’s sleeping too late and not being able to get up or even shift it in the opposite direction, so shift it later, for example in a much older person who is falling asleep at 8:30 but waking at 3:00 AM and really wants to sleep through until 4:00 or 5:00 AM. So we can then shift the body clock.
Now the way to shift the body clock is not by shifting the time that we go to bed. That’s what everyone actually tries to do because that seems to be the easiest to control. But we can’t wheel ourselves to get to sleep. The bit of the whole sleep-wake process we can control the timing of is what time we get up. We can set an alarm and non-negotiable. Right, this is the time I’m getting up.
So we can control that part of it. So if we’re wanting to shift the body clock gradually earlier in the teenage example, you can for example get them to wake up half an hour earlier each day and each day that same routine of light for 20 or 30 minutes with activity as soon as possible after arising, the melatonin 12 hours before the get-up time. You shift that whole pattern gradually earlier and earlier until you get to the desired time.
Now that all sounds pretty simple. You should fix things within a week. It’s not that straightforward. The biology is often pretty straightforward. So particularly for a teenager who has not got other health problems, they can shift their body clock even up to an hour a day backwards in that earlier pattern. But the tricky bit is actually complying with the treatment. It’s not easy. It doesn’t always go well to start with. You got to be pretty persistent. You’ve really got to sort of take ownership of it and understand how to use the tools and have confidence that it’s going to work.
So whilst theoretically it can shift pretty quickly, in practice I find that’s often not the case. Maybe that’s because I see a lot of people who really got hardcore problems, who have had difficulties over a number of years and have tried simple strategies at home and they haven’t worked. Maybe I’m a bit biased in what I see. But I do find it tends to be a bit harder than what people think it should be and that can mean they give up a bit early. So you just got to stick with it.
I don’t get it right – most of the time, I actually don’t get it right the first go around. It takes us a couple of gos of using the tools, doing it when we think it should work, then having a look at what happened. Have we got a partial response? And then fine-tuning the instructions and saying, “Right now, we’re getting a bit better at it. Let’s move things back.”
Also there are other times when it can take a lot longer to shift people’s body clock. That’s more in people with physical illness, mental illness, medications. Depression is one condition where I really often see the body clock be quite resistant to shift. But if we’re persistent, we can get there.
Now a couple of examples. So this first example is a sleep diary of the teen student I was saying, who hadn’t been able to get to school for a couple of terms and it was really causing problems for her and her academic performance and problems with her parents in terms of they – the mornings were not pleasant for anybody in the household, trying to get her up.
Though we’re getting frustrated as well because she couldn’t fall asleep at night and was sleeping from – at around 1:00 AM and getting up at around 10:00 AM. So we put in place the strategies I just outlined in terms of advancing her circadian phase and because she was otherwise well, we wanted to go pretty quickly. So I was aiming for about 15 minutes each day of just setting an alarm 15 minutes earlier each day. The light exposure, the activity in the morning and moving the body clock backwards and it actually worked pretty nicely.
So over a 12-day period that you can see on the graph there, so got around four hours earlier. She was getting to sleep around 11:00 and getting up around 8:00. So, pretty close to the time that they’re after in terms of school and was actually working for school, because they only have a very short trip to school. So that’s an example of when things go really nicely and it’s pretty straightforward.
Next example is another person I was working with and their sleep diary is turned on its sides, so it does look a little different. But they were really having trouble of not getting to sleep until 6:00 AM, not getting up until 1:00, 2:00 PM and then having periods across six months and this is a six-month sleep diary where they would run into a non-24-hour sleep-wake rhythm pattern. That is a very long period and a phase that just kept drifting. So about an hour later every single day and they essentially slept around the clock around once a month.
So that took a period of entrainment as the first step, which is what this next slide shows at what happened over the next six months. First we got the rhythm set and felt like we could control the rhythm and set that at around 4:00 until noon we had them sleeping. Then over the next six months, could gradually bring that rhythm back. But after six months, had them sleeping from around 11:00 PM through until 8:00 AM.
The great news is, is this is someone who had been out of work for around six years and a young adult, highly skilled in the IT industry and once we got the rhythm back on track, back into fulltime work. Now it’s a couple of years down the track successfully working, yet had been unable to work for six years and no other treatments apart from maintaining this circadian phase. But it was tough and it took a lot of persistence and we didn’t get it right the first time. So that’s one of the key messages.
So to sum up, the key inputs to the circadian system are light, physical activity and meals and using those and paying attention to those means you can actually manipulate the circadian rhythm, get it working better for you and get the timing at a time that’s going to better suit you. But it’s not always straightforward and I don’t always get it right and I got a reasonable amount of experience and it does take quite a bit of persistence.
So don’t feel if you give it a crack for a week and nothing happens that, oh, it’s not going to work for me. It probably will work for you but you just might need some more expert help.
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