Townsend Letter for Doctors and Patients

Biometric analysis of controlled clinical study for sleep formulation on multiple parameters of aging-related dysfunctions

Biometric analysis of controlled clinical study for sleep formulation on multiple parameters of aging-related dysfunctions

Marcelo Suarez


In this paper, the authors establish the construct and timing of sleep, and explore the common reasons why adult men and women fail to achieve restful, restorative sleep. From this, the authors submit that natural sleep promoting agents can quicken the time necessary to fall asleep (sleep latency), reduce nighttime awakenings, and improve morning alertness. In a prospective controlled study performed from September to October 2002, the authors investigated the effect of daily administration of a natural sleep promoting agent (assigned the identification of Sleep formulation #33760-C) on non-melatonin-deficient nonelderly non-insomniac subjects. During a four-week treatment period, the effect of dally administration of Sleep formulation #33760-C among 21 adults, 7 males and 14 females, mean ([= or -]SD) age 53.4 ([+ or -]10.7) years was investigated. From subjective assessments reported by study subjects, the study demonstrates the value of natural sleep promoting agents (such as sleep formulation #33760-C) i n resetting the sleep-wake and endogenous melatonin rhythm, thereby improving overall health status, including quality of life (QOL), in the study participants. This study attests to the appropriateness of employing a multimodal mechanism involving supplemental nutrients to treat delayed melatonin onset.


Many of us equate achieving nightly restful, restorative, rejuvenative sleep with health, vitality, physical prowess, and mental agility. Fully one-third of our existence is meant to be spent in dreamland where the majority of the body’s repair and rejuvenation mechanisms perform their life-saving, life-enhancing functions.

But with 30 million Americans suffering from sleep difficulties — some of them life-threatening — there is clear and compelling scientific evidence that modern-day lifestyle puts health and longevity at risk. Disturbed, disrupted sleep can contribute to:

* high blood pressure

* heart disease

* diabetes

* depression

* chronic fatigue

* frequent colds or infection

Additionally, when we are not well rested, we do not perform at our mental and physical best while awake. Daytime sleepiness is a leading cause of on-the-job accidents and mistakes that can put your job at risk. We are more irritable and agitated and make poor decisions. We also tend to pack on the pounds, as we become prone to reach for snacks to keep us awake.

Thus, it becomes paramount that, in today’s world, we preserve our quality sleep. Melatonin, a natural hormone produced by the body during darkness, and when part of a formulation of natural sleep promoting agents including botanicals and nutrients time-tested for promoting restful, restorative sleep. Natural sleep promoting agents (such as sleep formulation #33760-C) can quicken the time necessary to fall asleep (sleep latency), reduce nighttime awakenings, and improve morning alertness — attesting to the appropriateness of employing a multi-modal mechanism to treat delayed melatonin onset. The clinical study of this formulation demonstrates the value of natural sleep promoting agents in resetting the sleep-wake and endogenous melatonin rhythm, thereby improving overall health status, including quality of life (QOL), in the study participants.

The Construct of Sleep

Rest is not synonymous with sleep. As you have probably experienced, we can lay wide awake at night for hours. Likewise, activity is not synonymous with wakefulness: the average person changes position between 80 and 100 times while asleep. Sleep is a state of being which generally matches a set of electrical and physiological patterns. These electrophysiological markers can be grouped together in a framework scientists refer to as our sleep architecture. By understanding the construct of sleep, we are better able to understand how we can improve our sleep.

Stages of Sleep

Sleep is not a single state. It is a dynamic and active process. During sleep, we usually pass through five phases of sleep:

* Stage 1: Light sleep, in which we drift in and out and can be awakened easily. Our eyes move very slowly and muscle activity slows. People who wake from stage 1 sleep often remember fragmented visual images. Some people experience sudden muscle contractions (hypnic myoclonia), often preceded by a sensation of starting to fall.

* Stage 2: Our eye movements stop and our brain waves become slower, with occasional bursts of rapid waves called sleep spindles.

* Stage 3: Extremely slow brain waves called delta waves begin to appear, interspersed with smaller, faster waves.

* Stage 4: The brain produces delta waves almost exclusively. Stages 3 and 4 make up our slow-wave deep sleep phase, from which it is difficult to wake the sleeper. In deep sleep, there is no eye movement or muscle activity. People who are awakened during deep sleep do not adjust immediately, and often feel disoriented for several minutes after waking.

* REM (Rapid Eye Movement): Our breathing becomes more rapid, irregular, and shallow. Our eyes jerk rapidly in various directions. Heart rate increases and blood pressure rises. Legs and arms become temporarily paralyzed, as this is the stage of sleep in which we dream (paralysis protects us from acting out our dreams and possibly harming ourselves or those around us).

The stages of sleep progress in a cycle, starting with Stage 1 and proceeding through REM, with the cycle repeating several times during the night. A complete sleep cycle takes 90 to 110 minutes on average. The first few sleep cycles each night contain relatively short REM periods and long periods of deep sleep. As the night progresses, REM sleep periods increase in length while deep sleep decreases. By morning, we spend nearly all our sleep time in stages 1, 2, and REM. In general, nonelderly adults spend almost 50% of their total sleep time in stage 2 sleep, about 20% in REM, and the remaining 30% in the other stages.


Insomnia is the perception or complaint of inadequate or poor quality sleep, which may cause daytime tiredness, lack of energy, difficulty concentrating, and/or irritability. Insomnia results from one or more of the following situations:

* difficulty falling asleep

* awakening frequently during the night

* awakening too early in the morning

* awakening feeling unrefreshed

As such, insomnia can be considered to be a fracture of sleep architecture.

About 60 million Americans a year struggle with insomnia, which affects about 40% of women and 30% of men. The instance of insomnia tends to increase with age, more commonly affecting those age 60 and over. People with a history of depression also may be more likely to experience insomnia. An estimated 8 million doctors’ office visits a year can be attributed to insomnia.

Insomnia is most often caused by:

* stress

* disturbances to the sleep-wake schedule (see The Free Run below)

* environmental noise

* extreme temperatures

* changes in the surrounding environment

* side effects of medication

Mild cases of insomnia often can be prevented or cured by practicing goad sleep habits. For more severe insomnia, doctors may prescribe medications. The US market for prescription sleep products exceeded $1 billion in 2001 — a remarkable 30% growth over the previous year. However, because sleeping pills often cease to work after prolonged regular use and long-term use can interfere with good sleep, the option of natural sleep promoting agents (such as sleep formulation #33760-C) can be an appealing alternative.

The Clock of Sleep

Much of the behavior and physiology of plants and mammals — humans included — is based on a biological timekeeping process called the circadian rhythm. From the Latin circa meaning “about,” and diem meaning “day,” the circadian biological rhythm roughly approximates the Earth’s 24-hour day.

Circadian rhythms are generated by internal pacemakers and persist regardless of external cues in the environment that indicate the time or length of the day. However, entraining agents known as zeitgeibers (German, meaning “time givers”) — such as the light-dark cycle of the Earth day — help the circadian rhythm stay regular (see Staying In Synch below).

The concept of the circadian rhythm is a key concept in modern medicine. Internal pacemakers regulate most of our physiology and behavior: when we sleep and are awake, when we eat and drink, fluctuations in body temperature, and the functions of body systems including endocrine and reproductive. The optimal operation of these systems, and the optimal interaction between body systems, is essential to longevity.

Staying In Synch

Generally speaking, the internal clock that regulates the human circadian rhythm is synchronized (entrained) primarily to the light-dark cycle. As a result, our circadian rhythm has a periodicity of approximately 24 hours. Maintenance of the circadian rhythm relies on two specific parts of the brain:

* Through a pathway from the retina (of the eye) to the hypothalamus (a structure located deep in the center of the brain), information about light and dark cycles is delivered to the suprachiasmatic nucleus (SCN). The SCN, a pair of pinhead-sized structures that together contain about 20,000 nerve cells, is considered to be the mammalian circadian pacemaker. The SCN governs functions that are synchronized to the sleep-wake cycle, most notably hormone secretion. In lab animal experiments where scientists lesion the SCN, the animals lose their circadian rhythm; transplants of intact SCN restored the circadian rhythm.

* From the SCN, nerve impulses travel via the pineal nerve to the pineal gland. In lower vertebrate animals, the pineal gland has an eye-like structure and functions as a light receptor. It is considered by some to be the evolutionary forerunner of the modern eye, giving rise to its moniker “the third eye” by ancient civilizations. In humans, the pineal gland is the center for the production of the hormone melatonin and is essential in regulating the sleep-wake cycle.

The Free Run

In humans, our 24-hour rhythm can become shifted, either advancing (to become shorter than 24 hours) or lengthening (to become longer than 24 hours). These shifts are often caused by an absence or change in the entraining agents (zeitgeibers), and scientists refer to this temporary de-synchronization as the free-run. Most commonly, these shifts are short-lived, causing us to feel sluggish or fatigued, decreasing our physical or mental performance, and/or causing difficulty sleeping. If, however, the circadian disruption persists, some of us may run the risk of developing medical and/or psychiatric illness or begin to abuse drugs or alcohol (generally, an ineffective attempt to self-medicate our malaise).

In modern society, thanks to technology and a 24/7 lifestyle, the two most common free-run culprits are jet lag and shift work. Travel between multiple time zones has become commonplace for most adults, and many of us travel abroad and thus across six or more time zones. Jet lag can cause a shaft-lived (transient) discrepancy between internal 24-hour rhythm and external time cues, leaving many of us to feel out of sorts when we arrive at our travel destination.

Men and women who work nighttime shifts can experience a long-term (chronic) disruption between our internal 24-hour rhythm and external time cues. About 60-70% of shift workers have difficulty sleeping, and they typically get less sleep over 24 hours than day workers. Shift work-related de-synchronization symptoms include those seen in jet lag, but because the situation causing the disruption may be prolonged, other more significant problems may manifest. Studies have shown shift workers to be at increased risk of heart problems, digestive disturbances, and emotional and mental problems, all of which may be related to irregularity of their sleep.

Temperature Tumble

Another important cyclical internal mechanism in the human body is that of our body temperature. Scientists have determined that the process of thermoregulation is under its own unique internal timekeeping system, and is not a response to environmental cues. Our body temperature clock generally follows a pattern where:

* body temperature is lowest during the overnight hours

* body temperature slowly rises starting in the morning around 8a.m.

* body temperature peaks after dinnertime, around 7-9p.m.

* body temperature starts to fall around 9-11p.m.


Melatonin is the hormone through which our brain regulates our internal biological block. Secreted by the pineal gland located in the brain, melatonin production in humans is dependent on the light-sensitive SCN system. Thus, we produce the highest levels of melatonin during nighttime. Levels gradually decline as daybreak approaches, in response to the cue of bright light that signals the production cycle to shut down:

In healthy people, levels of melatonin start to rise between 8.00pm and 9.30pm, peaking between 1.00am and 3.00am, after which levels gradually decline to low daytime levels. As we age, we produce decreasing amounts of melatonin. Older folks have, on average, less than half the levels of melatonin circulating in their bloodstream than younger people. This may suggest a biological reason why many of us experience difficulty sleeping as we grow older.

Melatonin Promotes Restful, Rejuvenative Sleep

Melatonin supplementation can promote sleep in healthy adults through several mechanisms. First and foremost, melatonin can improve the quality of sleep, which results from better sleep efficiency caused by a repair of fragmented sleep architecture that is often seen with age. In a study involving men and women of an average age of 76 years and complaining of trouble with sleep quality, Dr. Garfinkel and colleagues from the E. Wolfson Medical Center (Israel) found (1995) that melatonin reduced movement during sleep. As a result, sleep was better maintained throughout the night and the seniors awoke more refreshed. This finding was independently corroborated by a similar study published by Dr. Haimov and team from Technion-Israel Institute of Technology, who also found (1995) that the seniors did not adapt to the melatonin and thus were still benefiting from it after taking it for two months. Most recently, Dr. Pawlikowski and colleagues from the Medical University of Lodz (Poland) asked (2002) women age 64 to 80 years to take 2 mg of melatonin at bedtime for a period of six months. At the end of the study, better than 1 in 3 of the women reported improvement in sleep quality. Additionally, the markers of sleep efficiency improved — namely their time to sleep (latency) fell, the number of times they awoke during the night reduced, and total hours of sleep increased.

The capacity to repair fragmented sleep architecture points to the therapeutic value of melatonia in insomnia. The benefit of supplementation with this hormone for increasing total sleep time and promoting subsequent daytime alertness have been reported since 1990. Most recently, Dr. Andrade and team from the National Institute of Mental Health and Neurosciences (India) gave (2002) melatonin to men and women diagnosed with insomnia but for whom prescription sleeping medications were not an option due to other existing medical conditions. After just one week, the patients got to sleep faster, had a deeper and better sleep, and felt fresh in the daytime.

Secondly, melatonin promotes quality sleep in healthy adults by inducing a drop in body temperature. Dr. Satoh and colleagues from Akita University School of Medicine (Japan) found that as little as 1/2 mg of melatonin in healthy young men could suppress core body temperature and thus permit a thermal environment conducive for falling asleep quickly. In seniors, Dr. Dawson and colleagues from University of South Australia have shown (1998) that melatonin causes a significant reduction in core body temperature. Subsequent work (2002a) by a team led by Dr. Cardinali from the University of Buenos Aires (Argentina) found that older men and women given melatonin were able to get to sleep faster.

Thirdly, melatonin is a potent phase-setter. It can resynchronize the sleep-wake cycle in people whose internal clocks are chronically or frequently disturbed. In patients with a delayed sleep-wake and melatonin rhythm, 5mg of exogenous melatonin, administered 1 hour before individual dim-light melatonin onset, advances the sleep-wake and endogenous melatonin rhythm. Furthermore, these patients feel more refreshed in the morning, their cognitive processing speed accelerates, and their quality of life (QOL) improves. Other studies have reported that patients with a delayed endogenous melatonin rhythm caused by whiplash trauma that subsequently damaged the neural connections between the retina and pineal gland, can benefit from the potent resetting capacity of this hormone. In a study involving 16 patients, melatonin 5mg administered 5 hours before individual endogenous melatonin onset improved quality of life.

In an important study by Dr. Duffy and team from Brigham and Women’s Hospital (Massachusetts), the researchers compared the sleep patterns of men and women in two age groups — older (around 68 years old) versus younger (around 24 years old). The average wake time and bedtime for the older men and women occurred earlier than younger subjects by one hour or more. Likewise, the nighttime peak of melatonin hormone secretion in the older group occurred one hour earlier. Taken together, these advances in wake time, bedtime, and nighttime melatonin peak suggest that seniors who are experiencing poor sleep may suffer from what may be considered a shift in their internal biological clocks, creating desynchronization not unlike that experienced by night workers. As such, melatonin may be of phase-setting value as we age.

Among nappers, melatonin shortens sleep onset while increasing alertness while awake, without impacting the regular night-sleep time.

For those of us who like to sleep late on weekends after a grueling workweek, melatonin may be useful for reducing the lackluster awakening we encounter on Monday morning. Dr. Yang and colleagues from the City University of New York observed (2002) that sleeping for 2 hours more on Saturday and Sunday can cause a 31 minute delay in the melatonin rhythm. By administering one single dose of melatonin on Sunday night, Dr. Yang was able to minimize the “weekend drift” of the circadian rhythm. As a result, come Monday morning, the men and women awoke to report far less sleepiness and better mood, and performed better on cognitive tests than sleeping in without taking melatonin over the weekend.

Melatonin’s Bonus Anti-Aging Potential

Numerous scientific studies suggest an important role for melatonin as an anti-aging therapeutic agent. In an experiment by Dr. Reppert and colleagues (1995), mice bred with a genetic defect that caused the animals to produce only a short-lived peak of melatonin at night lived shorter lives than mice with the intact gene. Conversely, experiments conducted as early as 15 years ago document that melatonin supplementation is effective at extending the lifespan of lab animals. In 1987, Dr. Pierpaoli and colleagues from University of Bologna (Italy) found that mice that received the hormone in their drinking water at night lived 20% longer than their unsupplemented counterparts. Dr. Anisimov and team from the Petrov Research Institute of Oncology (Russia) found (2001) that 5.4 times more mice administered melatonin lived past their expected lifespan. In a new study (2002) by Dr. Bonilla and team from the Universidad del Zulia (Venezuela), researchers found that daily supplementation of melatonin in fruitflies inc reased maximum lifespan by 33%. Much of the life-extending benefit of melatonin in these cases is suspected to be a result of the potent antioxidant activity of the hormone. Inside cells, melatonin intercepts free radicals — highly charged molecules that steal electrons from other molecules, a repetitive cycle which ultimately leads to DNA damage that is now associated with over 100 human clinical conditions including autoimmune diseases, heart disease, cancers, and more. In Dr. Anisimov’s study, they found that melatonin inhibited free radical damage in both the brain and liver tissue.

Melatonin also is important for proper immune and inflammatory responses. Dr. Chen and colleagues from Anhui Medical University (China) found (2002) that rats fed a diet supplemented with melatonin showed an increase in the production of IL-2 (an immune factor responsible for mobilizing the initial immune response) cells and thymocytes (cells that mature to become T-lymphocytes, responsible for attacking infectious invaders). Additionally, the inflammatory response causing arthritic joints in the rats was suppressed.

Dr. Maestroni from the Instuto Cantonale di Patologia (Switzerland) found (1998) that melatonin administered to lab animals enhances the release of Th1 cells (helper cells that coordinate the immune response to infectious agents). Additionally, in humans, Dr. Maestroni observed that melatonin enhanced the production of IL-6 (activates B-lymphocytes that secrete antibodies in response to infectious agents). Taken together, he suggests that his findings indicate the role of melatonin in mounting the proper immune defense when the organism is exposed to infectious agents.

Dr. Pawlikowski’s study (2002) of melatonin supplementation in healthy elderly women found it also improved the levels of two hormones considered to be anti-aging in and of themselves:

* The researchers observed a slight but significant increase in IGF-1 (insulin growth factor 1), a natural anabolic growth factor that is a primary end-product of the HGH (Human Growth Hormone) pathway. IGF-1 exerts many similar anti-aging benefits as HGH — increases lean body mass, decreases fat, builds bone and muscle, and improves blood sugar profiles in type 2 diabetics. Additionally, IGF-1 been shown to repair peripheral nerve tissue damage caused by injury or illness, and new research suggests that this growth factor may be of benefit in neurodegenerative diseases. Dr. Pawlikowski’s findings indicate that melatonin, with its direct potential to correct fractured sleep architecture (a factor in insomnia), can also exert indirect anti-aging benefits such as promotion of IGF-1.

* The team also observed an increase in the level of dehydroepiandosterone sulfate (DHEAS) along with a higher DHEAS-to-cortisol ratio. DHEAS is the blood marker for the circulating hormone DHEA, which is the most abundant hormone in the human body. DHEA is involved in the manufacture of all the sex hormones (estrogen, progesterone, testosterone), and scientific studies have found that DHEA is a key hormone involved in immune defenses and maintaining blood sugar levels. DHEA follows a similar age-related decline as that observed with HGH, so by age 65 our bodies make only 10-20% of what we did at age 20. DHEA acts as a potent counterbalance to the stress hormone cortisol — so improving the ratio of DHEA to cortisol can be of anti-aging benefit.

The level of a melatonin metabolite (6-sulfatoxy-melatonin) secreted in urine decreases both as we age and as a result of chronic diseases like Alzheimer’s and coronary artery disease. Interestingly, Alzheimer’s Disease, affecting an estimated 4 million older Americans, has been correlated to a decrease in the amplitude and organization of circadian rhythms regulating sleep-wake, hormones, and body temperature. When Dr. Jean-Louis and team from University of California gave melatonin to patients with Alzheimer’s, they found (1998a) it enhanced and stabilized the circadian rhythm, reduced daytime sleepiness, and improved mood. In separate research, the team also found (1998b) that melatonin given to older men and women with mild cognitive impairment (not Alzheimer’s) improved sleep quality and the ability to remember previously learned items.

Scientists have suggested a link between the pineal gland and cancer as early as 70 years ago. Yet, it is only within the last 20 years, as the mechanism of melatonin has been revealed, that this connection has become better defined. Experiments conducted over the years suggest the pineal gland has an influence on the formation and growth of malignant tumors. Recently, alterations in melatonin concentrations have become associated with breast cancer, prostate cancer, colorectal rectal cancer, and uterine cancer. Moreover, melatonin has been reported to be helpful in the therapy of advanced cancers of various types. Dr. Lissoni from the Ospedale S. Gerardo (Italy) reported (2000) that daily melatonin supplementation was able to enhance the anti-cancer activity of IL-2 and IL-12 cells in patients with metastatic solid tumors. Dr. Maestroni from the Instuto Cantonale di Patologia (Switzerland) found (2001) that melatonin promotes hemopoiesis (formation and development of blood cells). A study published in the B ritish Journal of Cancer in 2001 reported that the incidence of breast cancer in women who had become blind before the age of 65 was 49% lower than that in normally sighted women. Because melatonin production is high in the blind at all times of the day, the researchers offer this finding as suggestive of the anti-cancer role of melatonin.

Clinical Study of Natural Sleep Promoting Agent Sleep Formulation # 33760-C

Study Protocol

This study investigates the effect of daily administration of a natural sleep promoting agent (assigned the identification of Sleep formulation # 33760-C) on non-melatonin-deficient, non-elderly, non-insomniac subjects.

A prospective controlled study performed from September to October 2002 investigated the effect of daily administration of Sleep formulation # 33760-C among 21 adults, 7 males and 14 females, mean ([+ or -]SD) age 53.4 ([+ or -]10.7) years.

To qualify their participation in the study, all subjects lacked a pre-existing medical condition. Subjects experienced fatigue and sleep, memory and concentration disturbances. Furthermore, dim-light melatonin onset (DLMO) occurred later than 9.30pm. Exclusion criteria were: age under 18 years, prior use of melatonin, pre-existing sleep disturbances, use of monoamine oxidase (MAO) inhibitors, pregnancy or wish to become pregnant during trial, serious psychiatric or neurological disease, sleep apnea syndrome, liver disease or renal failure, and alcohol abuse. Before taking part in the study, patients gave written informed consent. The study was approved by the local Medical Ethics Committee.

To assess the influence of natural sleep promoting agent Sleep formulation # 33760-C in patients with non-reported sleep disorders, this outpatient clinical evaluation consisted of a randomized, double-blind, placebo-controlled, parallel-group trial. Nutritional, psychological and sleep characteristics were collected from subjects at the onset of the study. Medical and sleep history was obtained by use of a questionnaire. Each participant was required to complete a Sleep Formulation Study Test Registration/Agreement.

The clinical study consisted of a one-week baseline period followed by a 4-week treatment period. In the treatment period, subjects received either Sleep formulation # 33760-C [an oral supplement capsule containing melatonin (1.5mg), Vitamin B6, Vitamin B12, Passionflower, Mucuna pruriens, valerian, lemon balm, Hops strobile, chamomile, and astragalus root], or an identical-looking placebo. Study subjects were instructed to take their capsule daily at 1-hour before dim-lights.

Two groups were randomly designed for administration of the sleep formula. For the first two weeks, Group 1 received one capsule (1.5mg), given only once a day, about an hour before dim-lights; Group 2 received two capsules (3mg) given only once a day, an hour before dim-lights. For the second two weeks of the study period, both Groups 1 and 2 increased the first two weeks’ daily doses by 50%. Follow ups were conducted at days 15 and 30. To ascertain whether the patients chose to go to bed earlier on their own accord, they were allowed to go to bed when they felt tired, rather than at a scheduled sleep time during the trial.

Study Data Collected

Everyday during the baseline week and in the fourth week of treatment, subjects were asked to make entries in their sleep diaries. Each day, patients were instructed to record lights-off time, sleep latency, number and duration of nocturnal awakenings, wake-up time and get-up time in a diary during the baseline week and the fourth treatment week. Asleep-related scale running from 1 (not true) to 5 (very true) for feeling refreshed in the morning was also rated daily. The mean values over 7 days were computed.

Twenty-four hour sleep patterns, sleep latency, and sleep efficiency were obtained by questionnaires. Medical Outcome Study Short Form- Questionnaire. L was measured using the Medical Outcome Study Short Form-questionnaire. This questionnaire has also been validated for use in different populations to assess physical, mental and social health, compiling an indicator of total quality of life (QOL). Subsets of item scores, forming five dimensions, were summated and then transformed to a scale from 0, which indicated the worst health state, to 100, indicating the highest health state.

As assessed by self-perceived health and subjective wellbeing as sleep patterns by questionnaires, the study measured changes in health-related quality of life (and in particular, scores for energy, emotional reactions and vitality) so that data from subjects administered Sleep formulation # 33760-C could be compared against counterparts who received placebo.

During baseline week and the fourth treatment week, sleep parameters which could be correlated to quality of life (QOL) were assessed. For these determinations, the study utilized the Study Short Form-questionnaire, simple and opposite reaction time tasks, and the Clock-Test.

Dim-light melatonin onset (DLMO), a measurement of the endogenous 24-hour salivary melatonin profile is a reliable marker for circadian phase position. To assess differences in circadian phase position, it is not necessary to measure the complete 24-hour profile. The time at which melatonin starts to rise in dim light (DLMO), is shown to be particularly convenient, as it can usually be obtained before sleep. Salivary samples were collected hourly from 9:00pm to 11:00pm. To prevent suppression of melatonin secretion by light, the patient remained from 10.00pm onward in a dimly lit environment. In the fourth treatment week, patients did not take the study medication during the night of saliva collection. The time at which melatonin secretion reached 4 ng/L was defined as DLMO. DLMO was calculated as the linearly interpolated time of the first sample above 4 ng/L that was preceded by a lower value. When the melatonin concentration increased but did not reach 4 ng/L by 1.00am, we surmised that DLMO occurred later than 1.00am. In these cases, DLMO was noted as occurring at 1.00am.

Sleep was also recorded in four cases by ambulatory cassette EEG+actigraphy and polysomnography. At the third and fourth night of the baseline and fourth treatment week, sleep onset was measured with an actigraph. This motion-sensing device was attached to the non-dominant wrist, from 6.00pm until 8.00am. Actigraphic monitoring measures movements in 30-second periods. Sleep onset, as derived from the wrist activity, was recorded and averaged over the two nights. Ambulatory polysomnography (PSG) was recorded at inclusion and in the fourth treatment week to assess lights-off time, (sleep) latency between lights-off time and sleep onset, wake-up time, actual sleep time, number of nocturnal awakenings that lasted longer than 2 minutes percentage of slow-wave sleep (%SWS), REM sleep and sleep efficiency (actual sleep time divided by time in bed from sleep onset). The PSG results derived at inclusion (to rule out sleep apnea syndrome) were used as a baseline measure.

Study Findings

In the initial weeks of the study, 80% of the subjects reported:

* Significant increase in sleep efficiency, defined as the percentage of time when the subjects actually slept

* Significant decrease in nocturnal awakenings

* Significant decrease in sleep latency, the number of minutes between the time the subject went to bed and the time the subject fell asleep


* Twenty-five percent (25%) of those subjects responsive to Sleep Formulation #33760-C reported more sleep and better next-day alertness after two weeks of melatonin supplementation.

* Both sleep efficiency and sleep latency further improved for 33% of the subjects after the fourth week of study.

At the end of the four-week long treatment period, subjects completed a final survey questionnaire. The survey sought to determine the efficiency of supplementation with natural sleep promoting agent Sleep formulation #33760-C and its possible side effects. Eighty-four percent (84%) of the patients reported that the formulation treatment was helpful, with reported side effects no greater than placebo.

Of the 21 patients who entered the trial one female patient withdrew from the group receiving natural sleep promoting agent Sleep formulation #33760-C because the trial protocol was too demanding. One patient reported a slight increase in headaches during the first 3 days of supplementation. No other side effects were reported.

Of the 17 subjects who completed the study, 80% demonstrated a dose-related improvement in sleep efficacy:

Additionally, natural sleep promoting agent Sleep formulation #33760-C increased the percentage of time the subjects spent in bed (sleep efficiency) and decreased the time the subject reclined in bed and the time the subject fell asleep (sleep latency):


Memory and subjective feeling of refreshment in the morning was found to be greater in subjects receiving natural sleep promoting agent Sleep formulation #33760-C (first through fourth weeks of treatment versus placebo group):


Study Conclusions

The mean DLMO of the patient group at baseline [11.l2pm ([+ or -] 1:24h)] occurred 1:20h (95% CI for the difference of means: 0.53 1-207h) later than in the healthy control group. Mean ([+ or -]SD) baseline DLMO occurred at 11.13pm ([+ or -]1:18h) in the group receiving natural sleep promoting agent Sleep formulation #33760-C and in the placebo treatment group at 11.24pm ([+ or -]1.15h). In the fourth treatment week the mean ([+ or -]SD) DLMO was reduced to 9.54pm ([+ or -]1:39h) in the group receiving natural sleep promoting agent Sleep formulation #33760-C and to 11.02pm ([+ or -]1:02h) in the placebo treatment group. A significant melatonin treatment interaction effect was found [F = 5.66, degrees of freedom (df) 1, p = 0.021). There was no melatonin treatment inter-action effect at the melatonin levels at 9.00pm (F = 0.526, df 1, p = 0.471), 10.00pm (F = 2.38, df 1, p = 0.128), 11.00pm (F = L82, df 1, p = 0.182).

There was no significant treatment interaction effect found for the polysomnography and diary parameters. However, treatment with natural sleep promoting agent Sleep formulation #33760-C advanced actigraphic awakening F = 6.68, df 1, p = 0.0 15). Within the group receiving natural sleep promoting agent Sleep formulation #33760-C (n = 16), mean actigraphic awakening time shifted from 8.35am ([+ or -]1:09h) to 7.43am ([+ or -]1:08h). Within the placebo group (n =5) awakening time shifted from 8.10am ([+ or -]1:36h) to 8.30am ([+ or -]1:36h). From this, we conclude that patients with delayed melatonin onset, melatonin 3-4.5mg, administered 1-2 hours before endogenous melatonin onset, advanced endogenous melatonin onset and actigraphically registered wake-up time.

Additionally, natural sleep promoting agent Sleep formulation #33760-C did not affect treatment-time interaction on the dimensions of questionnaire after the first treatment month. Effect size ranged from 0.00 to 0.26 and from 0.08 to 0.36 after 1 month of natural sleep promoting agent Sleep formulation #33760-C and placebo treatment, respectively. Baseline mean reaction times fell within the lower range of normal values. There were no significant effects noticed for natural sleep promoting agent Sleep formulation #33760-C on the results of the clock test or the reaction time test.

The influence of exogenous melatonin contained in natural sleep promoting agent Sleep formulation #33760-C on endogenous melatonin onset, lights-off time and wakeup time was found to be in accordance with the chronobiotic properties of melatonin. The delayed endogenous melatonin onset, together with the capacity of exogenous melatonin to advance melatonin onset, suggests that melatonin treatment might be beneficial for subjects with a delayed melatonin onset.

The results of this study of natural sleep promoting agent Sleep formulation #33760-C suggest that it may be prudent to ascertain circadian rhythms in patients before considering them for treatment with a supplement formulation containing melatonin and other sleep-promoting nutrients and botanicals.

Further clinical trials of natural sleep promoting agent Sleep formulation #33760-C involving n larger number of patients and n longer treatment period will assist to ascertain the role of a placebo effect and whether a low QOL is related to the desynchronized circadian rhythm and sleep insomnia experienced by study subjects. Future studies will also reveal whether natural sleep promoting agent Sleep formulation #33760-C directly improves QOL by influencing circadian rhythms, associated with daily functioning or indirectly, by first influencing the sleep-wake rhythm.






Financial Burden of Insomnia

Health Care Services for Insomnia(in millions of dollars)

Outpatient physician visits $660.00

Psychologist visits 122.40

Social worker visits 76.30

Sleep specialist visits 18.20

Mental health organizations 153.00

Inpatient hospital care 30.80

Nursing home care 10,900.00

Data complied from sources including Murphy K, “An epidemic of

sleeplessness,” Business Week, May 8, 2000, 161-162; Problem sleepiness,

NIH Publication No. 97-4071, National Heart, Lung, and Blood Institute

(National Institutes of Health), September 1987.

Note: Table made from bar graph

Distribution of Dose: Weekly Group Schedule

Group 1 Week 1-2 1.5 mg 1.5 mg 1.5 mg 1.5 mg

Group 2 Week 1-2 3 mg 3 mg 3 mg 3 mg

Group 1 Week 3-4 .3mg .3mg 6subj 3mg 6subj 3mg

Group 2 Week 3-4 6subj.3mg 6subj.3mg 6subj.3mg 6subj.3mg

6subj.4.5mg 6subj.4.5mg 6subj.4.5mg 6subj.4.5mg

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Dr Marcelo Suarez-Bigetti

American Academy of Anti-Aging Medicine

CME Director

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773-528-0000 ext. 8

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