By K. Jensen, medSask
Cognitive behavioral therapy for insomnia (CBTi) is a non-medication method for treating this sleep disorder. An important component of CBTi is sleep restriction which acts as a “hard reset” for sleep patterns. Research has shown that CBTi works as well or better than sleeping pills and most guidelines now recommend CBTi as the treatment of choice for insomnia lasting longer than one month.
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By Nikole Tattrie, RD
A Look at Prebiotics and Probiotics
Health research in the past ten years has seen a tremendous focus on gut microbiota - that is, the tens of trillions of bacteria living in our intestines that influence our health for better and for worse.
Including a delicious recipe -
Tutti Frutti Muesli
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By Juliet Sarjeant, BScPT, MSc
Have you seen this product before and wondered what it was? Or what it was for?
Impressa® Bladder Supports were released in Canada a few years ago with a fair amount of media fanfare. It is the first over-the-counter, temporary vaginal support (pessary) to be approved by the FDA for use in stress urinary incontinence (SUI).
By Carleen Desautels
A creative reflection on mid-life.
What is Insomnia?
Insomnia is defined as a difficulty falling asleep and / or staying asleep during the night which results in feeling unrested the next day. The amount of sleep we need is different for every person. Some people may only need five hours while others may need more than nine hours. It’s not the number of hours you sleep but rather how rested you feel when awake that determines if someone suffers from insomnia.
People with insomnia often complain of feeling tired and irritable during the day and may have difficulty concentrating at work or school. In addition, ongoing insomnia may be associated with many mental and physical disorders such as anxiety, depression, high blood pressure, heart disease and diabetes.
What Causes Insomnia?
A few nights of poor sleep every now and then happens to everyone. Usually we can relate these “white” nights to something going on in our lives at the time (an illness, a new job, etc.) and when the situation resolves or we adjust to it, our sleep returns to normal.
For some people, however, their sleep problems continue for months and years even though the “precipitating” cause is no longer an issue. Insomnia lasting more than one month is often due to poor sleep habits, false beliefs about sleep and / or excessive worry about insomnia. Keep in mind that certain medications or medical / mental health issues can also interfere with sleep - check with your pharmacist or doctor.
Changes made to sleep patterns in an effort to correct insomnia such as napping during the day, going to bed earlier, and /or staying in bed later in the morning, may actually have the opposite effect and “perpetuate” insomnia. Worry about getting enough sleep can worsen insomnia by making it difficult to relax and “shut down” the mind. As insomnia persists, a person may become “conditioned” to being awake in bed and find that, no matter how tired, they immediately become wide awake as soon as they go to bed.
How does CBTi work?
CBTi addresses the underlying causes of insomnia using a combination of strategies which teach people how to change unhelpful sleep habits and negative thoughts and develop healthy sleep patterns. These strategies include:
• Tracking your sleep patterns in a personal sleep diary.
• Sleep restriction - reducing the time you spend in bed to the time you are actually asleep. This increases the drive to sleep and at the same time consolidates sleep to promote more restful sleep. Sleep restriction requires setting regular bed and wake times and getting out of bed and leaving the bedroom if awake during the night.
• Stimulus control - limiting of activities in the bed room just to sleep (and intimacy) in order to rebuild the association between the bedroom and sleep. This includes not reading or watching television while in bed.
• Thought therapy - identifies and addresses any negative or misleading thoughts or beliefs about sleep.
• Relaxation techniques - helps to counteract conditioned arousal at bedtime or when awake in the middle of the night.
CBTi versus sleeping pills
Sleeping pills are easy to take and may work more quickly in the short term, but they lose effectiveness in the long term. However, even though they quit working, coming off them becomes hard because dependence develops within a few weeks.
CBTi is challenging in the short term, but eventually results in long term improvement. For CBTi to be successful, a person has to commit to follow sleep and stimulus control restrictions which may be somewhat difficult at first. Also, it may take a few weeks of CBTi before sleep begins to improve. Once a person has learned how to manage their sleep with CBTi, however, the benefits are long-lasting. Even though relapses may occur, a person trained in CBTI has the skills to re-establish a healthy sleep pattern.
Sleeping pills have side effects such as next day drowsiness and fatigue which may weaken concentration and slow reflexes. This can have a negative
effect on work or school activities as well as increase the risk of car accidents and injuries from falls.
When taken regularly as mentioned above, many sleeping pills also cause physical and psychological dependence. Physical dependence means that stopping the medications will cause withdrawal symptoms such as anxiety, irritability, shaking, upset stomach, and short-term worsening of insomnia. Psychological dependence means believing that you won’t be able to sleep without the medication.
Other than the temporary increase in daytime fatigue that may occur during the first few weeks of sleep restriction, CBTi is not associated with side effects. In addition, CBTi can help people reduce or eliminate their dependence on sleeping pills.
How to access CBTi
Although the treatment of choice, CBTi is not widely available mainly due to a lack of trained providers. Your doctor may be able to refer you to a sleep specialist but there is often a long waiting list.
PharmaZzz is a research group at the U of S, College of Pharmacy & Nutrition program which trains pharmacists to provide CBTi to people with insomnia. The aim of the PharmaZzz program is to increase patient access to CBTi and reduce inappropriate use of sleeping medication through our community pharmacists. For a list of pharmacists who can offer CBTi, go to
http://www.medsask.usask.ca/documents/cbti-documents/PharmaZzz%20Pharmacists.pdf
Other options for CBTi include:
• Online programs:
Shuti at www.myshuti.com
Sleepio at www.sleepio.com
• Self-help books:
The Insomnia Workbook (Silberman);
Say Good night to Insomnia (Jacobs);
Sink into Sleep (Davidson)
Pursuing one of the above ways to obtain CBTi is very likely to be your best option in the long run. For more information, contact Karen Jensen Co-Investigator, PharmaZzz Group: email cbti.program@usask.ca; phone 306-966-1330.
Prepared by
K. Jensen, medSask;
Reviewed by
L. Regier, RxFiles and
Dr. A.J. Remillard
College of Pharmacy & Nutrition
University of Saskatchewan
August 2017
References:
1. Toward Optimized Practice. Assessment to management of adult insomnia. Clinical Practice Guideline. December 2015. Available at http://www.topalbertadoctors.org/download/1920/Adult%20Insomnia%20CPG.pdf?_20160327212120.
Accessed August 2017
2. Qaseem A, Kansagara D, et al. Management of chronic insomnia disorder in adults: a clinical
practice guideline from the
American College of Physicians. Ann Intern Med. 2016. http://annals.org/aim/article/2518955/.
3. Centre for Effective Practice. Management of Chronic Insomnia.
Jan 2017. Available at https://thewellhealth.ca/wp-content/uploads/2017/01/20170116_Insomnia_FINAL.pdf.
Accessed Aug 2017.
4. Perlis M, Jungquist C et al. Cognitive behavioral treatment of insomnia a session-by-session guide. New York, N.Y: Springer; 2005.
5. Jacobs GD. Say good night to insomnia. New York, N.Y: Henry Holt; 2009.
Similar to a fingerprint, each of us has a unique, personalized makeup of helpful bacteria in our gut that plays an important role in digestion, production
of some vitamins, protection from harmful microorganisms, and immunity. Interestingly, babies are born sterile, meaning that one’s makeup of gut bacteria develops after birth and is from thereon influenced by environment and diet.
The microbiota is ever-changing and has the ability to adapt when one’s environment or diet changes.
Sometimes these adaptations are necessary and good. For instance, if you travel and are exposed to foods you don’t normally eat, your microbiota may change to aid with the digestion of these different foods. Other times, these adaptations may cause harm. Infections, antibiotic treatments, poor diet, and other factors such as stress can lead to a loss of good bacteria, which causes an imbalance within the microbiota. This imbalance has
been linked to health problems such as functional bowel disorders, inflammatory bowel disease, allergies, obesity, and diabetes. Unfortunately, it isn’t always possible to stop this imbalance from happening. For instance, antibiotic treatment may be necessary if you are sick, even if it wipes out the good gut bacteria along with the bad. So what can you do to protect the health of your gut?
Here is where probiotics and prebiotics enter the picture.
Probiotics take the main stage when it comes to optimizing your gut microbiota. Probiotics are live bacteria which can provide beneficial effects when the right amount of the right type is given. Probiotics come from bacteria that is used for fermenting food and are most often found in yogurt, cheese,
and milk. Lactobacillus and Bifidobacterium are common probiotics whose beneficial effects have been studied - identifying these on an ingredient list may be a first step to incorporating probiotics into your diet.
Just as a car does not function without fuel, probiotics require a source of nutrition in order to thrive and multiply. This is where prebiotics step in.
Prebiotics simply act as food for probiotics, allowing them to thrive and reproduce. Prebiotics are found in small amounts in several common
foods, including garlic, onions, tomatoes, bananas, apples, bran, and almonds. Sometimes prebiotics and probiotics are added to foods that don’t naturally contain them. To identify whether a food contains prebiotics, check the ingredient list for Galacto-oligosaccharides (GOS), Fructo-oligosaccharides(FOS), Oligofructose (OF), Chicory fibre, or Inulin.
Probiotics and prebiotics are increasing in popularity with increasing evidence to back up their claims. However, there are a few catches when it comes to using them:
If you are keen on food sources of probiotics, be aware that not all fermented foods have probiotic activity. Some fermented foods (i.e. shelf-stable sauerkraut or pickles) have been heat-treated or filtered, which removes the live bacteria. Similarly, the live bacteria in sour-dough bread do not survive the baking process. Often, food labels will provide clarification whether live and active cultures are present in the food, thereby indicating whether or not they have probiotic activity.
If choosing to make fermented foods at home, be aware of the possible risks of non-controlled fermentation and seek out appropriate instructions for how to do so safely.
If you are interested in supplement forms of prebiotics and probiotics, be aware that just as each person has a unique makeup of gut bacteria, some people may respond to a specific probiotic strain while others do not. If going this route, it is wise to seek the advice of a health professional with expertise in the field of probiotics. Certain probiotic strains and dosages are indicated for certain health states or conditions - using a one-type-to-fix-all approach may be a waste of your money.
Lastly, be aware that the natural health product industry in Canada is loosely regulated, and testing various probiotic supplements has revealed that products may not contain the number of live bacteria they claim to. It is important to determine which brands are reputable in terms of the production, processing, and storage of probiotic supplements before you invest your money and health into them.
There is still lots we have to learn about probiotics. As with all aspects of health, isolating and implementing one single intervention - such as the introduction of a randomly-selected probiotic supplement - may not have as immediate or dramatic of an effect as you want. What is clear is that a
healthy gut microflora can help improve or maintain several different aspects of your health, and probiotics and prebiotics can play an important role.
If you are looking for more information, check out these sources:
https://www.eatrightontario.ca/en/Articles/Digestion/The-Pros-of-Probiotics.aspx
http://www.gutmicrobiotaforhealth.com
Tutti Frutti Muesli
Looking for a simple breakfast recipe that includes food sources of probiotics?
½ cup nonfat or low fat plain yogurt
½ cup blueberries, fresh or frozen (thawed)
¼ cup diced apple
¼ cup diced banana
¼ cup unsweetened muesli
1-2 tsp honey or maple syrup
Stir together yogurt, blueberries, apple, banana, muesli, and honey or maple syrup to taste in a bowl. You can also make this ahead - cover and refrigerate for up to 1 day.
Biography - Nikole Tattrie
Nikole Tattrie is a Registered Dietitian working in SHR with professional experience in both acute- and long-term care. Her current roles at work include enhancing food/nutrient intake among hospital patients, designing tubefeed and parenteral nutrition regimens for patients who are unable to meet nutrition needs from food, and helping to educate and prepare hospital patients for discharge to their home environments. Aside from her SHR role, Nikole has undertaken other work and volunteer opportunities including leading community kitchens and educational sessions at a women’s shelter in Saskatoon and helping to establish an infant feeding program for at-risk mothers and children in northern Haiti. Nikole has an interest in women’s health and finds it rewarding to use her nutrition knowledge to help people. She is pleased to contribute to the Hot Flashes newsletter and is eager to dig deeper into nutrition topics that are of interest to readers.
For those of you who are unfamiliar with the term stress urinary incontinence, it is urinary leakage from actions like coughing, laughing, sneezing and exercise.
Impressa is inserted into the vagina using an applicator similar to a tampon. The inside of Impressa is made of flexible, medical-grade silicone, surrounded with soft, non-absorbent polypropylene covering, with a polyester/rayon string for ease of removal. The structure of the silicone presses against and supports the urethra to prevent SUI.
Is Impressa intended for anyone? No, if you have urge urinary incontinence – a sudden need or rush to urinate - Impressa is not for you. It is also not intended for those women who have pelvic organ prolapse (a loss of support of one or more of the pelvic organs – bladder, uterus or rectum).
How to use it: The first step is to purchase a sizing kit that contains two samples of three different sizes. Start with size 1, and work your way up until you experience little to no leakage and you are still comfortable. Once you find the right size, you can purchase single-size packs thereafter. Impressa is only meant to be worn for a maximum of twelve hours over a 24-hour period.
Can Impressa be reused? No, it is to be disposed of after twelve hours (or before). All the packaging and the device itself goes into the garbage - none of the components of Impressa are recyclable, biodegradable or compostable. Nor can it be flushed – into the trash all of it goes!
Clinical Research: The literature related to Impressa (that I could find) is limited, with only a small group of 60 women included in the initial trial (Ziv, 2008). In that study, women wore pre-weighed pads that were weighed again after eight hours. They did this for a seven-day control period and then for 28 days of device usage. Eighty-five percent of the participants had a greater than 70% reduction in the pad weight with the use of the device, with the pad weight decreasing from a mean 16.85 grams per 8 hour period to 1.96 g/8h. In order to assess quality of life, three different tools were used and between 88 and 100% of participants had improvement in their quality of life over the length of the study (Ziv, 2009).
In terms of safety, the researchers reported no change in urinary flow with the use of the device nor was there a change in the amount of urine left in the bladder after emptying (Ziv, 2008). However, 68% of women reported an “adverse event,” including discomfort, pain, spotting and yeast infection. These were all short-term, minor events and decrease over the time of device usage. On the Impressa website, other potential side effects are listed: urinary tract infections, vaginal infections (including yeast) and increased bladder leakage.
Cost: According to the website there will be some variability of pricing, but an Impressa Sizing Kit will cost about $6.99, while a Single-Size Pack will cost about $13.99 (for a package of 10). You can also go the website (https://www.poise.com/products/impressa) for coupons to save $2 on Sizing Kit and Single-Size Pack purchases.
Other conservative options: If you are suffering from SUI, but are not interested in having surgery, there are other conservative treatment options available: reusable pessary and physiotherapy.
Reusable pessary: Impressa is considered a disposable pessary, but there are also reusable ones available. The Uresta comes in two sizes and can be bought online ($299 for a starter kit with a variety of sizes). The website recommends that the Uresta be replaced annually, but it is not clear why that recommendation is made.
Gynaecologists, urogynaecologists and some primary health care providers, including the nurse practitioners at the Pelvic Floor Pathway programs in Saskatoon and Regina, are able to fit women with reusable pessaries for a relatively low cost – between $45 and $80. These pessaries can be used for many years, as long as they are cared for properly.
Pelvic health physiotherapy: There are many pelvic health physiotherapists in the private sector (fee-for-service), and a few in the public sector scattered throughout the province, including the Pelvic Floor Pathways in Saskatoon and Regina. These physiotherapists assess the pelvis both externally and internally and, along with providing manual therapy, will prescribe a home exercise program to suit the individual needs of the client. For a listing of pelvic health physiotherapists in Saskatchewan, you can visit www.sasksurgery.ca/pdf/pelvic-floor-phys-therapists.pdf or http://saskphysio.org/find-a-physiotherapist
Take away message: Impressa® Bladder Supports seem like a reasonable option for women with mild SUI – they are convenient and readily available in pharmacies and grocery stores. If a woman was to use Impressa daily however, it could quickly get quite expensive. The Uresta, a reusable option, is quite expensive, but can be bought online. Other reusable pessaries need to be fit by a specially-trained healthcare provider. They are less expensive, but normally involve a wait time to access their services. Pelvic health physiotherapy is becoming more available across the province, both in private and publically-funded facilities. Physiotherapy requires repeated visits and commitment to a home exercise program. If a person has third party health insurance (e.g. Blue Cross), the physiotherapy appointments are covered.
Biography - Juliet Sarjeant
Juliet Sarjeant, BScPT, MSc graduated from the U of S School of Physical Therapy in 2002 and has been practicing as a pelvic health physiotherapist since that time. She earned her Masters of Health Sciences with a focus in pelvic health in 2014. Over the last few years, Juliet assisted in the development of the Pelvic Floor Pathway for the Saskatchewan Ministry of Health and in implementing a physiotherapy treatment option at St. Paul’s
Hospital for men post-prostatectomy. She presently shares her work time between the Pelvic Floor Pathway at Saskatoon City Hospital and McInnes Physiotherapy.
References:
Ziv E, Stanton SL, Abarbanel J. Efficacy and safety of a novel disposable intravaginal device for treating stress urinary incontinence. Am J Obstet Gynecol 2008; 198: 594.e1-e.7.
Ziv E, Stanton SL, Abarbanel J. Significant improvement in the quality of life in women treated with a novel disposable intravaginal device for stress urinary incontinence. Int Urogynecol J 2009; 20: 651-658.
Something inside me is undoing;
Unspoken tensions intensify.
An angry underside is revealing,
Not sure if it’s truth or its lie.
In contrast to the semblance of calm;
Boldly demanding a fight.
I feel like a ticking hormone bomb,
With a fuse just awaiting a light.
Short bursts of anger considering;
Not calculating cost or effect.
My body is tense with the listening,
For reasons to pounce or deflect.
Conspicuously unwilling to kowtow;
Breathe impatience with things not for me.
Speak aloud of the hurts I won’t allow,
Previously sworn to my secrecy.
Feeling mad by any description;
Insane and angry seem to collide.
It is from this dangerous position,
I am navigating through my mid-life.
Mid-Life Matters Series
Watch for Dr. Renee Morissette on CTV News at Noon with Jeff Rogstad. A series of short segments, Midlife Matters, on women’s health topics will be
presented on some Tuesdays during the noon show. Each topic will have a handout which will be on our website www.menopausecentre.org.
