Nutritional Keys For Restful Nights

Laurie Marbas, MD, MBA

Well, thank you. I am excited to be here.

Audrey Wells, MD

Yes, it is great to see you. I love this topic about using food as medicine. It pertains to sleep. I wonder if you can educate the audience on how you think about food and sleep together.

Laurie Marbas, MD, MBA

Yes, absolutely. I think many things affect sleep in chronic diseases. One of them, and when I say chronic disease, a few different things like type 2 diabetes, hypertension, high cholesterol, obesity—all of these things that we are dealing with, which appear to be in a normal state here in the U.S. especially—can have detrimental effects on us, even plus just our lifestyle in general. We are not very sedentary. We stay up late. Sleep, I feel, is the first thing that gets slashed, especially coming from ourselves as physicians and being educated in our medical system. But when it comes to food, I think it is important to understand that it not only affects sleep but also helps your overall health by decreasing and potentially reversing. Not always, but potentially reversing some of our most difficult and dreaded chronic diseases. I think diabetes is high on the list, but there are also hypertension, heart disease, high cholesterol, and sleep apnea that come with being overweight. When you also start eating these very nourishing foods, we are getting our micronutrients; we are getting vitamins, phytochemicals, all these amazing things, fiber, and all these wonderful things that not only reduce the current state of your chronic disease burden but also decrease the future risk. But they decrease a very important thing called inflammation. 

When you look at inflammation, is the root of so many chronic disease diagnoses. I think when we look at, for example, heart disease and we can measure it, it is a little bit difficult. You can measure what is called HCA and CRP, and this typically causes you to worry about the heart arteries and inflammation, but we put someone on a whole food plant-based diet, and they adopt the ability to eat fruits, veggies, beans, whole grains, nuts, and seeds, removing processed foods, and removing animal products that contain cholesterol that contain things that incite inflammation in the body. You will see a dramatic shift in numbers, but also how they are feeling. One of the first things that people say is, well, I cannot believe how much better I feel. I have so much more energy. My joints do not hurt. I am sleeping better, and my mood is better. I have some fun stories about patients who have depression, anxiety, or even schizophrenia. Believe it or not, I found that the more that they were in line with eating a whole new plant-based diet, the better their mental health was. There are just so many things that come along with feeding your body healthy, whole-plant foods.

Audrey Wells, MD

That is great information. I think this whole-food plant-based diet is out there as a way to achieve better health. One of the questions that I get a lot from patients is, What do you mean by processed food? I want to start by educating people. One of the shorthand ways that I think about it is to look for fiber in food. If there is no fiber, if there are great ingredients you cannot pronounce, that is processed food. I am curious to know what you would add.

Laurie Marbas, MD, MBA

Yes, I think we have to look at processes in two different categories. I would say there is ultraprocessing and then there is processing because even the beans themselves being cooked are being processed. If we go from oak groats to steel-cut oats to rolled oats to more instant notes, all that is being processed. Now, that is a better choice than eating the Jack in the Box hamburger inside and out or eating fried potato chips and different things like that. That would be more of the ultra-processed foods. Those are the ones that have the chemical compounds in the back that you need an advanced chemical chemistry degree to read. Another amazing rule of thumb that is fun to think about is: if your grandmother or great-grandmother were to read this label, would she be able to recognize these food substances on the back of it? If not, you might just want to put it back, and of course, there are other things that they are adding in. They are adding in added sugars that are going to be on food labels. You can see the added sugar component. That is very sneaky. They put it in everything. Why do you have to put sugar in marinara sauce or ketchup? I am just astounded at where we can find sugar. Sugar, and then also added salt. 

Again, it is just amazing to me all these things that food companies do. There is a way we always hear people talking about big pharma, but there is also the big food that has taken our ability or that we have handed it over to them. They just came in and took it. But we have handed over the cooking in our homes. Many of us go out to eat or go through drive-throughs, and we have surrendered the ability to feed and heal our families and ourselves in our kitchens. We have the tools there. It is not that hard. The food is delicious. The other thing is that this ultra-processed food hijacks our taste buds. If you have a child, for example, and you start them off with French fries at the age of two or as soon as they can chew, they are getting that salt, probably sugar, added in there somewhere. Now they do not understand that a strawberry should be considered sweet versus, let us say, ice cream. They do not understand that full-plant foods or whole foods, in general, are meant to be what our bodies are craving and should be looking to digest. But when we feed our bodies Franken foods, we get an output that is very different from what people expect. 

The other thing that I would like to highlight, and it might irritate some people, is that we have normalized the state of chronic disease in our country. We have a sick care system. We do not have a health care system. Initially, we always wrote drugs and prescriptions, like my daughter, who is now in her last year of family medicine residency. nothing’s changed. We are trying to see the tide of using lifestyle medicine, what it is called for, and all the guidelines. But for so many doctors, the first thing they look for is time because they are busy. There is a lot of stress, and there are a lot of demands on physicians to write another prescription. I am not saying that prescriptions do not have their place. They do. I am so thankful that we live in a time in society where we can utilize both. I certainly do utilize both regularly. But it is so much more powerful to see someone heal when they take control of their life and have the self-efficacy to move forward and make decisions that will not only affect their health and their lives, but the lives of their children, their family, their friends, and their neighbors. That is just tremendous. But ultra-processed food is what I would probably say versus just process because a lot of foods process in just cooking and of themselves.

Audrey Wells, MD

Yes, and I think what you are saying is a fair dose of common sense to just think about. I am just considering my son’s Halloween basket. There are lots of blue things in there, and that does not occur in nature. I know immediately that, besides the fact that everything comes in a wrapper. These are foods that generally should be minimized in the diet or avoided, especially if you have chronic disease states going along with that. I want to tap into an area of your expertise. You are a high blood pressure or hypertension expert, and high blood pressure and sleep have a bidirectional relationship. Can you describe that for us and how foods may be used to treat high blood pressure?

Laurie Marbas, MD, MBA

Yes, I think it is. First of all, it is very important to understand that you need to have your blood pressure controlled. I will never forget that my grandmother used to live with my husband and me many years ago, and I think I was in residency. She is like, I have just checked your blood pressure. What was funny was that I was like, Well, Grams, your blood pressure is elevated as well. Did you take your medicine this morning? I quit taking it last week because my blood pressure got better.

Audrey Wells, MD

I had the same experience with my grandfather. Yes.

Laurie Marbas, MD, MBA

Exactly. Everyone needs to understand that we need to control our blood pressure, and that needs to start with medications in the beginning. I tell people this can be a bridge, and if we incorporate certain lifestyle interventions, we may be able to get off one or all medications too. I have one patient who just started working with me and is on five blood pressure medications. Not only is that an amazing amount of medication, but what are the interactions here? When you look at sleep and hypertension, several things are going on because hypertension in and of itself is typically asymptomatic. It is not going to be unless you get an acute rise in blood pressure, get a headache, or have some vision changes. You are not going to notice it until there is something. Somebody measures it, or you are like, Guess what? You have chronic kidney disease, you have heart failure because of uncontrolled blood pressure, or you end up with a stroke or heart attack. These are the types of things that we are trying to prevent by controlling our blood pressure with medications and lifestyle interventions. How does that affect sleep? A great one is sleep apnea. If you sleep at night, you are at higher risk for hypertension, and medications can also interfere with sleep. All this is encompassing. 

There are a lot of nuances to it. But when you look at food, I want to focus on a couple of things. One is your decreasing inflammation. Inflammation can disrupt sleep. It can also lead to, again, other disease states like diabetes and other things. Let us say that you have uncontrolled diabetes, and now you are waking up to urinate in the middle of the night because you have been prescribed medication that increases your urination of glucose. That is just, again, one of the potential side effects of medications or your blood sugar being so high that you are urinating every few hours. Again, I just recently had a patient come in with blood sugars that topped out at 400. I put them on continuous glucose monitoring, and they did not want to be on medications. We had a little talk that changed. But now, because she has embraced a lifestyle approach and medications, we are weaning down on medications, and now, she is seeing blood sugars in the range where she should be, and she will be off medications probably in the next month or two months. Those are the things that can help. She also struggled to sleep. Now she is getting better sleep. When you have better sleep, you have less stress. Stress also helps with lowering the blood pressure. There are so many pieces to this. We could go into multiple rabbit holes. 

But getting back to your question about what foods, there are a couple of foods that have some real promise that I would encourage people to consume regularly, even if they do not have high blood pressure. They are just amazing foods. First of all, these are nitrate-rich foods. That would be something like the dark green leafy; you name them; there is spinach; there are beet greens; there is arugula; there are collard greens. Google a list of dark green leafy veggies and eat to your heart’s content; whichever ones you like, try different ones.

Something else is ground flaxseed. Ground flaxseed has been shown, if you are doing around two tablespoons or four tablespoons, you can see quite a significant drop in blood pressure, and it does not take much of a drop in blood pressure. Try to remember that systolic number to see a dramatic decrease in the risk of stroke and heart attack. Anything you can do that would be the first thing would be to make sure the appropriate controls are in place and then add in some foods, but also monitor salt intake. We want to keep our sodium level at around 1500 milligrams or less per day. That would include added salts. 

We are so used to eating out and again, eating processed foods that the sodium can creep in anywhere. You will be amazed. People eat 2,000 to 4500. People use a chronometer, which is a way to measure the food that they are eating. It will tell you multiple things—not only your proteins, your fats, and your carbohydrates—but it will also tell you other things like your salt intake, your calcium intake, and your iron intake. But that is interesting to look at the sodium content, and people are like, I did not realize. They were wondering why they were feeling swollen because of the water. The body’s retaining fluid helps balance out this high sodium intake, which raises blood pressure again, which makes you go to urinate in the bathroom in the middle of the night, which disrupts your sleep. 

Again, there are several things there. Ground flaxseed, dark green, leafy vegetables, and Hibiscus tea are interesting. There is some decent evidence there. I would do one cup, which is eight ounces with one teabag, and consume that with every meal three times a day, which would be fantastic. You will see a nice little bit of a decline there, but these are all additive effects. You can also incorporate exercise, especially isometric exercises, which have been shown to drop blood pressure better than aerobic exercise, or just regular resistance training, which you should be doing all the time, especially resistance training. But the isometrics do remember those PE wall squats that we have to do? The wall squats.

Audrey Wells, MD

I remember that. Yes.

Laurie Marbas, MD, MBA

It does suckers, but they have an amazing way of decreasing your blood pressure. What it is doing is decreasing the bristle resistance, meaning your heart is pumping. As it is pumping out the blood, there is resistance in the pipes or your arteries. When the isometric exercise occurs, it relaxes those arteries, and the blood can flow a little bit better. Again, there are so many ways you could do this, but exercise and, of course, sleep are very important for hypertension. Then I would just say, not only are we adding in these healthy whole plant foods, but we are moving some of those foods, especially the ultra-processed foods. I would not say even the animal products; that is where I tend to lean. The more you are eating, the more of the plant foods, the better off you are going to be in that sense.

Audrey Wells, MD

I agree. It is interesting to think about high blood pressure and sleep because you mentioned somebody that you were treating who is on multiple blood pressure medications. For cardiologists who are in the know, that is a red flag for an untreated sleep apnea condition. I very commonly get referrals from cardiologists when the blood pressure cannot be managed to do a sleep study and see if there is a problem with sleep-disordered breathing. The risk runs both ways. You can have high blood pressure, which is a risk factor for obstructive sleep apnea, and you lose the nocturnal dipping phenomenon. Your blood pressure does not dip during the night, as it should. When you talk about a whole-food plant-based diet, this is an ideal that is very different from the standard American diet, which is very sad. There is a funny mnemonic there. How would you recommend people get started if they are used to buying processed foods and keeping them at home? The kids are on board with these high, highly palatable foods, but foods that are low in nutrients.

Laurie Marbas, MD, MBA

Yes, absolutely. I think it will depend on the person and their current social circumstances. If you live alone and you are the only one you are feeding, it is very simple. You can either go overnight or some people just like to rip the band-aid off. Let us just throw it all out and get started. Others like to take a general, easier approach, especially when there are other people involved who may not necessarily agree with a whole plant-based diet. I would say, first of all, look at your current menu. Many of us eat the same foods regularly, even if it is takeout or something else. It is something you can prepare at home. Let us say you are already eating breakfast, and you enjoy oatmeal or smoothies. How can you add more fruits and vegetables? Can you move from regular dairy milk to non-dairy milk? There are so many to choose from. I particularly care about soy. Soy has amazing health benefits, and I have no idea why it has been demonized other than people think that phytoestrogens work differently. It competes with our natural estrogens, it decreases the risk of breast cancer, it helps bone health, and it helps cholesterol. It is a great protein and calcium source. 

Anyway, it is a fantastic resource if you are looking to, especially with children. There are a lot of healthy proteins and healthy fats, which are very important for brain growth and development. But you could switch to non-dairy milk. You could do almond milk; you could do those again. There are lots of things to look for on the label because many of them will have added oils or added sugars. You would be amazed. But try to eat one that just says soybeans or almonds in water. Another thing you should do is, look at some of the foods that you may have, like meat or something in them, and replace them with something like a legume, a bean, or a lentil. The one fascinating thing is that beans are associated with longevity around the world. It is the one food that is the common denominator when you look at all the things called the blue zones. 

There are five areas in the world, including one here in the United States, believe it or not, in Loma Linda, California. They are Seventh-day Adventists. Their religion is all about healthy eating. They exercise, they eat predominantly plant-based diets, and they have in blue zones the highest concentration of centurions, which means that the people who live to be 100 are not the people that we expect to be found in nursing homes and unable to care for themselves. They are living independently or with family, but they are still very active. You will see them watering the gardens; they are walking; they are doing all sorts of things. 

There is a wonderful documentary series called The Blue Zones by Dan Buettner on Netflix, now. I encourage everyone to watch it. It is just a fascinating watch, regardless of whether you want to embrace a plant-based diet. But you will see the habits that have evolved with these communities in these cultures that people embrace, and they naturally live in their environment, making healthy choices an easy choice. That includes eating a lot of plant foods. Whatever you can do in your environment to increase your plant consumption. I can show you here: I have sweet potatoes, apples, bananas, tangerines, and avocados. Just in my view right here, the kitchen is over there. We are opening up my refrigerator door. There would be strawberries, blueberries, and other things that I could easily grab if I wanted to snack. 

Those are things that, if you put them in front of you, you are more likely to consume, including kids. They see a piece of fruit that they can have ready access to, like a banana, for example. They are more likely to consume it than if candy is there or some potato chips are hiding in the pantry. Moving things out of the environment so they are not an easy choice is important. When you look at behavioral models like The Fogg Behavioral Model, the one lever that is important in behavior is making something harder, and you are less likely to do it. For example, if someone wants to stop smoking, they do not keep them locally. They have to go drive to the store to pick up cigarettes, or if you are having it, it is a little easier nowadays with the food, the apps, and DoorDash. Maybe you get rid of the Uber eats up in the DoorDash app and you commit. That you are not going to reinstall them. Instead, you will have to go drive to get some of those skills that will give you time to be mindful of what you are doing, and ask your questions, Is this something I want to do? 

If you have these thoughts and just have some time to reflect on them and still want to choose to consume processed food, that is okay. But at least you have made this a mindful process and not a mindless process. The other thing that I encourage people to do is look at recipes beyond just maybe replacing meat with beans and other things. Are you going online if there is something that you are enjoying? I grew up in New Mexico. I love Mexican food. I remember cooking enchiladas. I think even before I could see over the top, I thought having my mom would help me do that. By age eight, I was presenting enchiladas in the recipe, like the county fair. I dig plant-based eating, especially in the Mexican realm. The first thing I did when I went to a plant-based diet 12 years ago was: how do I incorporate these delicious flavors that I love, but in a healthier way? The person who is just Google realizes Google plant-based enchiladas. Or you could Google plant-based lasagna and plant-based Ethiopian or plant-based Lebanese. It does not matter. There are so many recipes. There are so many amazing people doing incredible things with food. I learned something every single day, and then you just go through it and look at it. Okay, that one looks simple, especially if it has simple ingredients and takes less than 30 minutes to cook. This is fantastic. Leftovers are also good. You can take leftovers with you to work, and those are just some of the beginning ideas for someone who wants to embrace a plant-based diet. 

Sometimes you can just start with breakfast for a week and then add lunch the next week and then dinner the next week, and it is important to have conversations and communication with those who live within your home, with you seeing the reasons why you value eating a healthier plant-based diet or at least a plant-predominant diet. If you are on medications for hypertension or diabetes, you must speak to your provider, health care provider, or physician to let them know that you do not have to tell them that you are eating a plant-based diet. Just say, I am going to start eating better. I want to eat more fruits and vegetables. I do not know if this will help my blood pressure or my diabetes, but I appreciate them keeping a close eye on me, and then they can decrease medications as they become appropriate, because it is very quickly. I have stopped taking six units of insulin in 72 hours, and as someone who has fully embraced a plant-based diet, I blew my mind. That was the first time I truly recognized the power of food. What is on the end of your fork is just such a wonder tool that we all have available to us. It is just a matter of a decision and a different choice.

Audrey Wells, MD

I am hearing a few things about what you are talking about. One is the mindfulness practice of not only what you are eating but also what you are buying. Thinking about how that food serves you or works against your health goals, I think that is a great division step. Another thing that I am hearing is planning. Making these choices deliberately in a way where you have to sit down and strategize and tell. These are concepts that fall back into your unconscious. It takes a little bit of work initially, but it is worthwhile. It is so beneficial. For those who may be considering making some of these transitions that you are talking about, my question would be: for something like hypertension or high blood pressure, how quickly would somebody see a result in their blood pressure once they have converted to a whole-food plant-based diet?

Laurie Marbas, MD, MBA

Yes, that is an amazing question and something very important. Just as one should plan for the obstacles in the planning piece, one must find them with any endeavor in life. If you plan for the obstacles, or at least think about what might inhibit you, or maybe learn from your past, what inhibited you in the past, and think about strategies and ways to go around those or change the path that you are walking, There is a great little poem called There is a Hole in My Sidewalk. I think if you are familiar with it, it is, so it is, like, I do not know, a page long. It is not very long, but it starts with chapter one. 

There is a hole in my sidewalk. I walk down it on the sidewalk. I fell, and I was so confused. I do not understand why, but it goes to like five chapters. She kept walking down the same road or the sidewalk and falling into this hole. But at different times, she has this realization that she was mindfully or not mindlessly walking down the street and falling in the hole, and by the fourth time, she is like, There is a hole in the sidewalk. She walked around it. But then, by the end, she chose a different street. It just leans back into understanding that we can learn from our past. There is no reason to feel shame or guilt about it, but we can learn from our past to make different choices in the future. We cannot use yesterday’s solutions for today’s problems because they did not work yesterday. The problems are still here. Let us look for different solutions. That gets me thinking about hypertension, and if you are using different solutions, something so powerful like lifestyle, medicine, and interventions like a whole plant-based diet, exercising, and getting better sleep, it can happen very quickly. 

Let us say I have this patient, for example, who is on three, four, or five different medications. It is very important that they have a blood pressure cuff at home and that they measure their blood pressure before they take medications. an hour or so after they take medications. The reason I say both is because, before I want to see what their baseline is without all these medications. For example, if I have a patient saying, Hey, Dr. Marbas, my blood pressure is running in the 130s, let us say, and they are taking four medications, Well, I am a little bit worried they might bottom out if they take four medications. Maybe we will stop two and see what the blood pressure does that day. 

An hour later, check it in the evening. If you want to sit quietly for 5 minutes, use a blood pressure cuff that will sit over the upper arm. Online is a great one. There is, and you could get them for like $35 off Amazon, and you could check three different blood pressures and average those out and over. Give yourself a minute or two between each reading. That would be a great indicator for you and your physician, your treating physician, of what your blood pressure is doing as you are embracing healthier lifestyle options. What I tell patients is that if you start having symptoms of low blood pressure, which is dizziness upon standing, or let us say that you were feeling good, you had great energy, and suddenly you are fatigued, you are tired, like you stand up, you are not necessarily dizzy, but man, I am just wiped out. I need to take a nap. The blood pressure might be a little bit low. It is interesting. When you eat a plant-based diet, you will see your heart rate start to climb. Heart rate, there are medications, for example, beta-blockers that control the output of the heart by decreasing the beats and the number of beats per minute. 

Now, some of these medications are required. If you have some type of arrhythmia or you have certain things like atrial fibrillation, those are medications you might need to be on or stay on, but maybe at a lower dose. Again, it may not be even just stopping because you do not just abruptly stop these on your own. There could be some serious side effects to that. If you are on a diuretic and have heart failure, you want to be very mindful and speak to your physician and get their guidance. But if you are symptomatic, that is a phone call that needs to be dealt with that same day. But if you are starting to see a blood pressure trend under 120 consistently, that is also, I think, in a place where we are ready to pull back on medications because it will not take long before you start to shrink even further. If you start hitting like 120 on top of that systolic blood pressure, I say 4 to 5 days of the week. I think it is probably time to talk to your doctor about a decrease in, or at least, or maybe even consider stopping it. You are on the lowest dose of medication already.

Audrey Wells, MD

I am hearing this can happen pretty quickly to stay on top of your symptoms.

Laurie Marbas, MD, MBA

Two weeks. Two months I would say.

Audrey Wells, MD

It is, yes. I want to put a plug-in for measuring your blood pressure at the same time each day because blood pressure has a circadian rhythm. It is important to compare that same time from day to day today. Fantastic information and actionable steps there. I want to thank you for putting out the benefits of the whole plant-based diet, which is going to reduce your inflammation, help your blood pressure, stay lower and more steady, and improve sleep, of course, because what you put in has a relationship with what you put out. The whole idea of how you feel the next day is something that I see all the time. If you are still tired, look at your food. Look at your food with a discerning eye and decide if you want to make some changes. Dr. Marbas, it has been fantastic to speak with you. Can you let us know where to go to find out more information or even work with you?

Laurie Marbas, MD, MBA

Sure. Absolutely. I am licensed in all 50 states, including D.C. I put you on medical licenses and I can take care of patients via telemedicine, and you can go to drmarbas.com, that is DRMARBAS.com, and it will describe everything that we do. I have The Healing Kitchen, which provides weekly live chats with myself and someone who provides recipes, her name is Brittany Jaroudi. She lost 70 pounds on a plant-based diet. She is only 4’11. She has gone through significant changes. She had sleep apnea, by the way. She had hypertension. She had high cholesterol, and she was young—23. That was eight or nine years ago. Now they are expecting their first baby. She is healthy. Brittany provides recipes. I provide the medical knowledge and answer questions. We do expert workshops every month, and we are also doing some other fun stuff that is coming in. But I am also happy to help take care of patients independently as well.

Audrey Wells, MD

Fantastic. Thank you so much. It was a pleasure.

Laurie Marbas, MD, MBA

Thank you. I thank you for having me. It was lovely.