Do Vitamins for Sleep Really Work?

Episode Intro:

Welcome to Dr. Ruscio, DC Radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates, visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now, let’s head to the show.

Dr. Michael Ruscio:

Hey everyone. Today I speak with Dr. Stasha Gominak regarding an interesting set of clinical observations and hypotheses she has – summed up very broadly and roughly – that vitamin D and the array of B vitamins are crucial for sleep. She mentions the B-50 and B-100 vitamins a few times. That’s just a B-complex where you have a dose of 50 or 100 per vitamin in the formula. Again, a very interesting conversation on the importance of vitamin D and the family of B vitamins for healthy sleep. She also ties a lot of this into the microbiome, which of course is something that is interesting to me and I think to our audience. I very much appreciated the conversation and I think that we may be getting to the same endpoint through different routes. She seems to be advancing this hypothesis that there’s importance for vitamin D and the B family, which I don’t disagree with.

DrMR:

However, getting those from lifestyle and diet – the D and the B’s – plus a healthy gut seems to be how myself, and we at the clinic, are seeing notable improvements in sleep. However, there is evidence showing things like vitamin D supplementation can also improve sleep quality. It was an interesting conversation. There were a few things I wanted to probe into or potentially push back on that I did not get the chance to do. I wanted to give her a real chance to make her case. One other thing I want to flag for you — there is a difference in the level of resolution in our our zooms. I’m a bit more “show me the evidence” in terms of clinical outcomes. Stasha is getting a bit more into mechanism. I do think these both have a time and a place, especially as she describes her story of discovering some of this while coming from a conventional neurology background.

DrMR:

I think her thinking through this in mechanism fashion makes some sense, and we also hit on this nice point about: What’s the optimum balance between evidence-based and clinic anecdote? The real main hypothesis she’s bringing to the table here is this interesting observation that some people might have essentially insomnia and/or non-refreshing sleep/poor deep sleep/poor REM sleep because of vitamin D deficiency. She gives some specific guidelines for dosing and levels, and also the family of B vitamins. Importantly, she also flags that higher dosages does not mean better. A great conversation with Stasha. One of the items that I pose is that when it comes to sleep, there are (high level) two things we’re trying to distinguish: Is the sleeping difficulty physiological? Or is it anatomical? This may sound easy, but if you survey 10 people, you’re likely going to have at least one indicator that a problem with sleep could be physiological and could be anatomical.

DrMR:

This is why I’m so proud of – and just want to flag for your attention – the clinic as a resource, should you need it. What we do there is that we obsess over an individual’s data, so as to be able build a case for “…there’s a high probability that insomnia, in this case, is physiological…” or “…there’s actually a lower probability, but there’s a fairly moderate to high probability that it is anatomical…” This matters because I’d like to think these conversations on the podcast are always compelling. But how do you know if you should be compelled by a given hypothesis therapy diagnosis? And that’s really where I feel a clinician comes in. Our clinic isn’t the only one in town, but I do think (as I’m sure you know at this point) we’re doing things in a unique fashion; really trying to hold ourself to a high methodological and scientific standard in the pursuit of helping patients improve their healthcare.

DrMR:

I just want to tie in the clinic referral should you be saying to yourself, “Do I integrate this? How do I integrate this?” I don’t want to profess to have Stasha’s protocol mastered, but again, I think we’re coming at similar endpoints through different avenues. Just as a quick aside here, (and to draw your attention to something that we’ll hit on in the body of the podcast) she mentions that her protocol seems to have this observation where some people will have a regression, perhaps, after six months. I’m sort of paraphrasing and also drawing an inference in terms of her rationale, but her feeling is there needs to be an updating of the B vitamin protocol if there’s a regression at the six month point because that (said loosely) tunes up the neurology, which then impacts the microbiome.

DrMR:

Now, I look at that differently in terms of knowing that people oftentimes will do quite well for a while, and then they can have a little bit of a regression with their GI. And then we revisit usually a simpler version of whatever protocol got them to their improvements in the first place. This might be tightening up some FODMAP restrictions, a touch more fasting, increasing the dose of probiotic protocol, and perhaps doing an elemental reset. The observation we have is similar in that people improve, and then some people have a regression. However, I think she’s coming at it top down and I’m coming at it from gut out. Anyway, just a few things there to flag. An interesting conversation here with Stasha on some physiological methods to improve your sleep, which is obviously and definitely, a pillar of health. And now we will go to the show.

DrMR:

Hey everyone. Welcome back to another episode of Dr. Ruscio, DC Radio. This is Dr. Ruscio, DC here today with Dr. Stasha Gominak and we will be discussing the topic of sleep. I think we’re going to have some new information to discuss in the realm of sleep. There’s always more here to learn it seems. Stasha – welcome to the show. It’s a pleasure to have you here.

Dr. Stasha Gominak:

Thanks, Michael for inviting me. I’m thrilled to be able to share ideas about sleep.

DrMR:

Me too. It’s something that I have struggled with myself, and I think everyone who gets a good night’s sleep says, “Man, I feel good when I do.” And if you string together a couple bad nights of sleep, you can feel quite terrible, so it’s definitely one of the foundational pillars of health.

DrSG:

I completely agree.

DrMR:

Within that realm, this is something that obviously you have a lot of experience with. Give us the quick primer on your background and what your clinical experience has been with sleep.

Dr. Gominak’s Background & Clinical Experience

DrSG:

My background is that I was trained as a neurologist. I went to medical school in the late 70’s, which is actually pivotal because I’m old enough that things were different both in the population and the diseases that we’re presenting before and after the 1980’s. I went to medical school at Baylor in Houston, which was my introduction to Texas. I live in Texas now, but I grew up and spent most of my life in California. I trained in neurology at Massachusetts General in Boston, and then I practiced for a long time in California. In 2004, I moved back to a small town in east Texas called Tyler, Texas with my husband. And then I started concentrating on sleep, mostly because I was desperate and I had about half of my practice in daily headache suffers. In early 2005, one of them told me that she wanted a sleep study. She wasn’t overweight and she wasn’t the typical look of someone we were taught to send for a sleep study. She had sleep apnea. She wore a CPAP device and her headaches went away. That totally challenged my ideas about why healthy, young women had daily headaches. From then on, I got very interested in sleep.

DrMR:

Those eye opening cases are always helpful to open up a blind spot that we may have had previously. I want to try to give people a high level of how you’re looking at sleep. Would it be fair for me to say – from a very broad heuristic – you’re looking at anatomical issues like airway and then also biochemical. Would those be the two buckets you would organize (so we can give people this structure) and then drill down? Or would you modify that?

DrSG:

I like the general idea because what we were all trained in was the anatomic look. The problem is if there’s nothing wrong with your airway, or if you don’t have sleep apnea on your sleep study, you’re often completely left. What changed when I was sending young, healthy females with daily headaches for sleep studies, was I was actually sending a group that was probably just starting to have a sleep disorder. Most of them had a problem with waking up in the middle of the night and not being able to go back to sleep, but not all of them. Many of them had lots of other complaints that were similar from person to person. “I can’t remember anything… I’m in a bad mood.” They were exercising, they were paying a lot of attention to their diet, and they didn’t have the usual pre-existing factors that were associated with sleep apnea. That means I had, by the end of several years, hundreds of sleep studies from people who didn’t feel good and had abnormal sleep, but there was no apnea. As soon as they’re not stopping breathing, then the next question is: Is this about the throat? Or what’s going on here?

DrSG:

Because they were otherwise young and healthy people, and I’m a neurologist, some of them had no rapid eye movement sleep… some of them had just apnea and REM… and some of them had no deep sleep at all. Well, those are things that don’t happen at the throat.

The Brain Stem, Sleep Paralysis, and a Pacemaker Cell

DrSG:

The controller of this is the brain stem sleep switches, so that brings us to more what you refer to as biochemistry of… what runs sleep? The brain runs sleep. It’s true that the anatomic outline of the throat can play a role in the throat collapsing, but it turns out that we all get completely paralyzed while we’re sleeping. That means if we get really paralyzed and if we get too paralyzed, especially in rapid eye movement sleep, where we specifically paralyze the head and face and throat, that we can actually have collapse of the airway only in that phase. That prompts you to start thinking, “Well, it’s kind of scary to think we get paralyzed. How do we get paralyzed? How do we get paralyzed and still wake up in the morning? That’s pretty weird.” It was actually my pulmonologist who was reading my studies, introducing the idea that we all get paralyzed in sleep, that I thought, “wow, that is really creepy.”

DrSG:

Who runs that? How are we getting paralyzed and how are we still living? That got me into a specific anatomy portion of the brain stem, and then it got me to single cell studies. People were taking single dopamine pacemaker cells in the brain stem that were part of the clump that control paralysis, and they were studying them individually, dropping little neurotransmitters on them – a little hair-like electrode in this one cell. It’s a pacemaker cell. That means it starts firing when you are born or before, as you’re developing, and it keeps firing your whole life. And I’m reading those weird, nerdy articles at the same time as I was seeing my patients and I realized that they’re dropping these neurotransmitters on these cells and watching them fire faster and then fire slower. And they’re actually studying the potential of… you could actually get a little too paralyzed and stop breathing and then not paralyzed enough and you could kick… and those are the two things I was reading on these sleep studies.

DrSG:

The chemistry of it came about by accident, but only really captured my imagination. I did this weird thing, which was to think about sleep on a single cell basis. How does this little pacemaker cell do its job? I had a clinical event, but I was thinking about it as this one little pacemaker cell trying very desperately to do its job. Do you want to ask questions about that or should I go on?

DrMR:

That’s a good point for me to interject. Just as a bit of context, we’ve done three, or maybe even four, podcasts now about upper airway resistance, obstructive sleep apnea, mandibular advancement, myofunctional therapy, positional device supports or similar objects that help you sleep on your side. We’ve done a pretty good job on airway and even expansive devices that can expand the palette and the arch. Ironically, even though I’m a gut geek myself and this podcast does a lot on gut health in general, we haven’t really drilled down into the biochemical aspect of sleep. And some of the remarks that I heard when going through an interview between you and Mike Mutzel… also an acknowledgement to one of our patients, Ed, for recommending you -thanks for putting Stasha on our radar screen… you were talking about vitamin D and the microbiome. This is something that we have hit on tacitly, citing some of the studies that show, for example, probiotic supplementation can improve insomnia and sleep quality, but we haven’t really delved too deeply in that. I’d love to focus us more into this physiological piece. And maybe you’re going there, but that’s what I’d love to focus on.

Vitamin D Receptors & Sleep Switches

DrSG:

That’s what comes next. You have a beautiful introduction there, and I don’t want to minimize all the other interventions you talked about because there’s always a need for an anatomical evaluation, as well as whatever we can do in the biochemistry. The rest of the stuff that wound up with me being into vitamins was by accident. I had an 18-year-old who had a sleep study that showed she slept 10 hours. As far as she was concerned, she was doing everything right. She would go to sleep. She’d wake up in 10 hours, but she was terribly tired and her sleep study showed no deep sleep. I spent five years prior to that seeing that you could sleep for 12 hours, but if you didn’t have any deep sleep, you would have headaches… you would have diabetes. There’s a portion of sleep where repair happens and we get paralyzed in that, and then there’s sleep where we’re doing other things.

DrSG:

It’s not that nothing is happening, but you have to have deep sleep and you have to have a certain amount in order to complete your repairs every night. There’s an aspect of this, which is about getting paralyzed correctly. How does that happen? Could that chemistry get screwed up? So, this gal has no deep sleep. She had a B12 of about 170. It was low enough that even I alerted to it. And I only did that test because she said,”… but I’m still so tired…” I really wasn’t the least knowledgeable about what would make her fatigued, but I could see her sleep study was terrible. She had a B12 of 172 and for the first time I thought, “Oh, there’s that dopamine still trying to do its work and it can’t do its biological job without this building block.” And I don’t even know B12 does. I know it’s very pivotal in sleep. There are a lot of articles about that.

DrSG:

It was that accidental stumble that made me think — What about all this stuff that has to be biochemical that can’t be anatomic? I know that in my particular population where documenting that their actual ability to get into deep sleep and transition between the phases of sleep is on the level of the brain stem. So, I did B12 levels, but then I threw in a vitamin D because somebody suggested it. I wasn’t interested it, but I was drawing blood anyway. Within about four months, it became very obvious that the B12 was there some of the time, but the vitamin D was low all of the time. That by itself is nothing remarkable because everybody knows that vitamin D deficiency is as common as having a cell phone. But it turns out after month four of sending out these notices saying, “Hey, your vitamin D is low, take 1,000 IU of vitamin D…” I had two guys that came back in… And as you mentioned, the clinical presentation is really the start of new ideas in medicine in my view…

DrSG:

So, two men come in the same week and they both say the same thing. “I’ve been wearing my CPAP mask for a whole year. I wasn’t getting any better. But then you sent me this note last time that said ‘Buy some vitamin D’ and within about a week, maybe three weeks, my sleep got better and my headaches went away.” I had already realized that the vitamin D was low all the time, but vitamin D being associated with sleep made no sense to me, except those two clinical observations led to a literature search. There was a guy named Walter Stump who wrote articles starting in the late 70’s who actually had studied whether or not there were vitamin D receptors in the actual sleep switches that make us paralyzed. These switches, these particular cell groups in the brain stem that I’ve been thinking about for months now, have vitamin D receptors.

Walter Stump’s Framework & Vitamin D as a Hormone

DrSG:

That made no sense to me, but Walter wrote hundreds of articles. He wrote over 300 articles about where the vitamin D receptors were. And by about 1982 had put together a completely logical framework in which to see D, which is still in my view the only logical framework in which to see it. He says this is a hormone, it’s a master hormone. It’s never been a vitamin. It’s not in the food. It’s not nutritional. We misnamed it for specific reasons, and that has led to a terrible misunderstanding of how to use this chemical and what it means. It is a hormone. We make it on our skin from sun exposure. It allows us to move other hormonal systems so that we can survive better when we move away from the equator. It affects metabolism – i.e. you’d like to be able to preserve your energy and not use it up when there isn’t any food because there isn’t any sun. You would like not to have your babies right at a time when you were short of food and hibernation is really about sleeping.

DrSG:

We know that animals hibernate, but even though we’ve known about this concept of Rickets being related to sun exposure for 100 years… There’s a beautiful publication in November of 1921 that shows the clinical disease of Rickets, which is not just about bone. These kids had failure to thrive and heart failure, and they showed that exposure to the sun would reverse the findings. The article is written as Rickets is one of the most common nutritional diseases, but it has never been nutritional. It has always been about sun exposure. It’s really upsetting, as someone who has practiced for 35 years, to go back and read these articles and realize that this is a matter of choosing to read certain literature and not choosing to read other literature. It depends on who you believe.

DrSG:

Now we move into the 1980’s and now sunscreen, air conditioning, computers, and the entire world starts to move indoors. And it’s become even more exaggerated since COVID. That means when Walter is writing his explanation of what D does — he writes about postpartum depression, about seasonal affective disorder (SAD), about how this will change when we have our babies. Therefore, he actually said that vitamin D deficiency is going to cause infertility. The problem is he’s writing all these articles before the epidemic of infertility and sleep disorders and all the other things that start showing up since the 80’s. Before those really catch on, he’s already written about it. Reading his articles, this made perfect sense to me that D would be related to sleep. And so I call this guy up and I say, “I just had this funny clinical observation. You’ve written all these articles about D yet, I don’t see any articles about D and sleep so I just thought I’d call you.”

DrSG:

By now, he’s in his 80’s and he’s retired so he’s willing to take a phone call from me. He says, “Yeah. Nobody has written about that, but it makes perfect sense. I have shown that there are these D receptors in these very cells.” In 2012, based on two years of clinical observation in my patients, I had a really simple question… I said, “Okay, everybody is D deficient… Could it be that there’s a blood level that could make my patients sleep better?” Really simple. The hard part is how do you get D to a certain blood level? That turns out to be a horrible mess in medicine at the moment, but I was completely naive and I didn’t have any preconceived notions.

DrSG:

I just started conservatively with 1000… 2000… because that’s what the FDA said. And then over a period of months, it became obvious that all of these women who had low levels, including me, and a sleep disorder needed much higher doses than 1000 or 2000, but that the dosing was quite variable. The thing that made the difference was not the dose, but the blood level, like every other hormone. Any clinician that has worked with hormones knows, “Hey, Michael, I think your complaint about whatever… your hair falling out… you can’t sleep is due to thyroid. Why don’t you just run down to CVS and buy yourself some thyroid hormone and I’ll see you back in a year. We’ll see how you’re doing.” Lay people know that’s crazy. You don’t mess around with hormones in that way. Yet, this is the way medicine is still giving out vitamin D.

Vitamin D Levels & Sleep Disorders

DrSG:

Since COVID began and D has hit the front page, everything is just going to get worse. It’s not going to get better in terms of how D is used. And we can talk about that towards the end if you’d like, but ultimately what happened was I spent two years trying to get D levels and it was not hard. And it’s been very consistent to show that a D over 60 (between 60 and 80) produces better sleep in a person who has a sleep disorder. That’s a very narrow question. That does not mean: What is the ideal human D level? That’s a completely different question. The question really is: What if I have a D that’s been low long enough that my body has actually spiraled down into a situation where I have a sleep disorder? That’s a different question. And if you look at human populations that are still doing hunter-gatherer/staying outside that have never actually lived in a house, their mean (not their range), but their mean D levels are in the 40’s and low 50’s.

DrMR:

Thank you so much for saying that because I can already see people trying to overreach or overshoot the landing with their vitamin D.

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DrSG:

If your intention is to be the best human you can be, then my question to you would be: Is there anything wrong with you? Because if there’s nothing wrong with you, including you feel great and you’re at the top performance of your age group, then you don’t want to be messing with this stuff. It’s a hormone. You would never say “well, why don’t I just decide I’m going to be the best I can be and just take testosterone… or just take thyroid…?” We already have experiences over the last 50 years of using hormones as pharmaceuticals. And they usually bomb out terribly because medicine does not know. Medicine is not biology. Medicine is humans interpreting things. That means we don’t really know what the ripple effect of giving a single hormone is going to be until we screw up a bunch of people.

DrSG:

There is a consistent level that has been consistent now for approximately 10 years in my hands. And that is 60 to 80 makes people who sleep badly, sleep better. The important part of this lecture is that D by itself is not the problem. It’s never the problem. The D was supposed to go up and down. That was its job. If you moved away from the equator, it went down in the winter and you slept longer. And then it went up in the spring and you got better again. The reason why this epidemic of things starting in the 80’s — sleep disorders, fibromyalgia, chronic fatigue, irritable bowel, ADD, autism — they’ve all increased over the same time span. They’re not all the same, but they are related to the loss of the microbiome. The piece that’s important to know is the D worked. It got people better, but it didn’t last. In fact, at two years of keeping your D between 60 and 80, most of us were feeling worse than when we began.

DrSG:

That is really important because there are millions of people out there taking D now. The second piece I want you to remember even more is that the D runs the microbiome. The four phyla that we have in our belly all need D. That means we only began to lose those four phyla as an epidemic around the globe when the D went down and stayed down so low, that we couldn’t support the normal foursome. Now, I thought that the phyla of the gut were going to come back as soon as I replaced the D. That was my belief. I knew it was attached. I didn’t have any depth of knowledge about it. But in actual fact, at the end of two years, the IBS was not gone and most of us had pain of various kinds. Some of us had burning pain in the hands and feet.

The B Vitamins

DrSG:

That situation where I was failing and my patients were failing two years into it, despite having good D levels, suggested that there was some ripple effect, like what I mentioned, where I really didn’t know all the implications of what keeping your D in a nice narrow band would be. And it felt like there was some other deficiency state occurring. This burning in the hands and feet — I’m a neurologist and my subspecialty is neuropathy. I know a lot about that. Burning in the hands and feet, both is extremely rare. And I had two of my patients walk in the door within a month of each other. Two years of taking D, they both had burning in their hands and feet that had just started in the last few months. That is a B vitamin-ish thing. I’ve only seen B12 take that away, but they were already on B12. That left me completely unable to answer why they had that, but suspecting there was something that I was doing with the D that was increasing the B vitamin use. And if they hadn’t changed their diets, why would their B vitamin be any different?

DrSG:

All the dogma we’ve been taught about B’s – B’s come from the food… there are no stores… you can’t hurt yourself with them… that all turns out to be a lie. There’s a second piece to this, which is very important. Luckily for me, there are now articles of substantiating these sets of ideas. My first idea was: If the D didn’t bring those guys back, we need them back. And what else could those guys want? So, I am completely uneducated in supplements. I went to medical school. They said, “If you give one B, give all of them.” That’s all I remembered. I used to read Adelle Davis, but as soon as I went to medical school, I was brainwashed out of it. So, I started to read recent B vitamin review articles. And most of those articles say things like Thiamin has a colonic bacteria source and a food source. Riboflavin – colonic bacteria source and a food source.

DrSG:

Every single B has a poop source and a food source. Well, the one thing that I had noticed was by the end of the two years of D, the IBS did not go away. Could that mean that the D was only part of the story? And if they lost their primary source of the B’s, what if all eight B’s originally came from the poop? Why would we have eight things called B anyway? That doesn’t make any sense. There’s A… and then there’s B one through eight… and then there’s C… and D… If you go into the history of the B’s, what you find out is every single one of these chemicals was reported as a bacterial growth factor. Bacterial growth factors were the actual biochemical pathways clarified and first discovered in bacterial populations because they used a culture of yeast plus the bacteria that was in the water and in the air.

DrSG:

They sat it on the top of the counter. And they sat it there at this warm temperature for when you’re going to make beer and bread. They poured that into the Petri dishes and they started to study bacteria that way. Our ideas about growth factors started in bacterial populations, but then were quickly presumed then to apply to humans. These bacteria have things that they require. Could it be that humans do too? Somebody back in the 1930’s must have recognized there were bacteria in our belly because somebody named all eight of them B’s. They clumped them together because they were really all found together in the same yeast bacterial mixture. Now, the weird part about that historically is that has been lost to our memory. In the 80’s, we were still teaching lots of stuff about vitamins to medical students, but now medicine around the 1980’s decided that it wasn’t part of our responsibility.

DrSG:

We’re going to leave it for lesser humans. We’re going to claim that we’re smarter than everybody else and we don’t have to worry about that anymore. That is a really bad attitude because these eight chemicals (and all the other vitamins) are the key of our biochemistry. How can you learn about medicine without knowing about these? This is a bizarre class struggle issue. Medicine is still strongly affected by this idea of class struggle and who is smarter. It’s weird when you think about science being affected by our primate-like desire to be in a certain pecking order, but humans are tribal animals. Unfortunately, medicine has decided that vitamins are not for us really smart people. Therefore, we have let a lot of things not be substantiated by science. As I was reading about the B’s, I had to go back to the 20’s through the 70’s to the B literature.

DrSG:

And there’s all sorts of other really good science there that says things like ‘there are stores of B5.’ Ultimately, what happened to me was that I became very suspicious that I am induced to B vitamin deficiency state, but I had no answer. One of my patients walked in the door with a book about pantothenic acid, which is basically the forgotten B vitamin. Nobody writes about it. Nobody cares about it. It is going to be the most important vitamin of the next 50 years. If you type it in anywhere, what you’ll see is there is no pantothenic acid deficiency because it’s in every food. I started to use it because this patient brought in a book. There were references from the 1950’s where they’d actually done very small experiments on convicts where they did really inappropriate things to them.

DrSG:

They tube-fed them block pantothenic acid by itself and they produced four things in only two weeks — couldn’t sleep, funny walking gait (a puppet-like gait), burning in the hands and feet, and their belly hurt. There are references. I said, “Oh my god, Mr. So-and-So has that funny gait that I haven’t been able to figure out. And these two women have this burning in the hands and feet.” So, I went out and I recommended this 400 milligrams of pantothenic acid because that’s what the book said. I started taking it, too. By accident, I actually just picked up B-100 because I had this one memory which was “if you give B, you should give all of them.” I really didn’t know what I was doing, so this is complete accidental, clinical observation. I give the recommendation of taking 400 milligrams of pantothenic acid, B-100, which is a combination of 100 milligrams or 100 micrograms of all eight.

DrSG:

I start giving that to people and I take it, and within four or five days, I realize my restless legs is much worse. It’s all day long now. This is the same stupid experience I had with the D that the literature is wrong. 500 milligrams is way too high, but that’s what everyone is saying. So, then my patients start to come back and I only recommended it for one week. 30 out of 40 of the people that I gave that recommendation to came back and said, “I took what you said.” The thing that is the basis of all of this is I had patients who were willing to come back and say “you were completely wrong.” That is an amazing thing. Most people, if you screw them up, they’ll just go “…terrible doctor… I won’t come back…” I have to actually thank any patient who was willing to come back and say, “Were you trying to kill me with this stuff?” and they would hold up this pantothenic acid bottle. It’s been sitting there on the shelf – 400 milligrams. We think of it as completely innocent. Instead, these patients consistently said, “I got so revved up and agitated. I couldn’t sleep at all. And some of them said, “I’m not ever going to see you again. You screwed me up.”

DrSG:

And I thought, “Whoa. This is really creepy.” Not only did this book recommend 400 milligrams, but every other authority recommends 400 milligrams and that’s the dose it’s in. Now, what I had done was to stop the 400 milligrams and take B-100. Within a day, my buttock pain that was completely unexplained, but I thought had something to do with sleep, went away. On 500, it didn’t get any better. On 100, it went away in a day. I then had other people come back and say this 400 milligrams nearly killed me, but I stopped it and with the B-100 that you gave me, all my pain went away in a day. And I was like, “Oh, that’s what happened to me! What do you think is going on?” I had no idea. To me, as a neurologist, this is an innocent looking vitamin. We’ve all been taught that vitamins will never hurt you. We don’t have any stores… you pee out the excess… These people are telling me stuff in the same words, in the same phrasing. I’m sorry, but that contradicts all that. There’s pantothenic acid in every food? There’s no way there’s pantothenic acid in every food. There’s no way.

DrSG:

In fact, if you look into the literature, pantothenic acid doesn’t exist in that form in our food. It exists as coenzyme A. Then there was an assumption made that coenzyme A would then be converted to B5 and then re-absorbed by the human being. But it turns out that doesn’t happen either. It really only comes from the bacteria and it’s not even completely clear that the bacteria in our belly use the coenzyme A that we eat. There may be other ways. So, when you’re mentioning prebiotics versus probiotics, the key in the background is it’s not just getting these foursome to come back. That’s the beginning step. The next step is: How do we change? How do we subtly dial that population in to match the best that we want to be? We can still manipulate the gut bacteria once the foursome is back and that’s where a lot of people have been writing things about prebiotics and that’s where all this is going to go.

The Four Phyla & Growth Factors

DrSG:

The important thing that I discovered was that you cannot get the primary foursome back again. Vitamin D was the reason why they left, but they won’t come back with just D alone. That’s really important because that means you must give them D + the eight B’s because what they really started with was a set of four phyla that were trading these growth factors with one another. So, one of them needs thiamine that their buddy right next door to them can use. One secretes thiamine and the other one secretes riboflavin. This means this was a symbiotic foursome of phyla and they grow up spontaneously. No other animal on the planet gives their babies probiotics. They just appear there. All they need is the D that comes in the mother’s milk because the mother is living outside and has enough D to do that. What that implies in the background is we could actually prevent all these things just by making sure that pregnant women have enough D in their blood to make the D in the breast milk enough to encourage the right microbiome to come back in the infant.

DrSG:

The rest of it is just keeping the D up. If you’ve never lost the microbiome, you never went through a period of living with an incomplete body, but when somebody comes in with a sleep disorder, what I learned was it’s never just D. They have to lose the microbiome to get sick. It’s losing the microbiome and literally the millions of things the microbiome does for us. That means that there are multiple diseases linked to several things that the microbiome makes. The eight B’s are just a part of the story, but in order to get them back, you have to recognize that those eight are actually growth factors. You give them all eight in big enough doses so that the human doesn’t suck them all up and leave the bacteria to starve. If you have a D blood level over 40 and you give B50 – those two together – and give it for three months, the bugs are back. It’s not very hard. It’s just a matter of changing your lens or changing your belief system.

DrMR:

A lot there to unpack. Zooming us way out, I fully agree that we want to be looking at these things upstream — How can we positively impact the gut microbiome? And there is evidence that shows that simple things like vitamin D supplementation has been documented to lead to positive and healthy shifts in the microbiome. That’s really exciting.

DrSG:

Yes. That was first published in 2020. That was the first article that actually, in humans, substantiated this idea. There was no microbiology substantiating that D was a co-factor bacteria, but it was actually studied first in 2020 in humans.

DrMR:

And there was earlier research that found – I think more clinically relevant and not necessarily establishing the benefit on the microbiome – but that vitamin D supplementation improves IBS. So, not surprising to me when I saw that study published, but it was a landmark study. Definitely. I was very excited when I saw that. And it’s also interesting what you’re remarking about the B vitamins and this ties in with a conversation we had recently with Kara Fitzgerald. In short, she’s been flagging for a while to relax with the super high dose B vitamins because we might actually create methylation disorders from over-methylating. And we want to predominantly try to get these things from foods. She didn’t say explicitly from the microbiome, but her position has been get these through food sources because these synthetic high doses can be damaging. You’re essentially saying the same thing, but in a different context, which I also appreciate and makes sense to me.

DrSG:

Let me add one more thing to that. When I stopped using 400 milligrams of B5 and instead moved to B-100, I then tried to give the same regimen to every person as they walked in the door. There’s this whole layperson’s book about giving 400 milligrams of pantothenic acid to people with rheumatoid arthritis. She herself had rheumatoid arthritis. The reason why she wrote the book, and the reason why the person brought it to me, was the patient said my pain went away and my sleep got better. Well, how come her patients needed 400 milligrams and mine said something like “I’m going to fire you.” What is different about my population having been on D for two years? That’s the only thing that’s different. There was a suggestion there that there’s a synergistic effect between D and B5. I didn’t know what it was at the time, but there was clinical evidence that if you’ve done D for a few years, you better not go and get that pantothenic acid, 400 milligrams.

DrSG:

The other thing that’s in the background of that is this stuff is like taking methamphetamine. It’s going right up into your brain. It is having an effect that’s dose dependent. Referring back to her saying large dose of B’s — what that means in the background is if you’ve lost your microbiome and you don’t have the normal production amount, not only do you not have normal production, but I just made your sleep better and tried to coax you into a state where you were making more repairs, therefore you actually used your B stores up completely. And then you began to manifest new things. And most of those things were terrible. Pain, arthritis, depression, anxiety, the stuff that relates to B5 is about acetylcholine making/using D and B5 and choline coming together in an equation that makes acetylcholine.

DrSG:

Acetylcholine is a neurotransmitter that does a lot of stuff in our body. At the time, I didn’t know any of that. What I thought was there’s something different once you’ve been taking D for a while. The other thing that’s creepy is: Why is this B5 pushing the equation? Does this mean that my bugs are actually completely straightforward running my mood, my anxiety, and my sleep? Therefore, my bug production of these specific chemicals are actually deciding whether I have a good life or not. That’s pretty creepy, but that’s what it means. Lucky for me, at the time I’m having those ideas, the GI literature is substantiating all the stuff that you’ve become passionate about. It’s not that when I go to the GI literature, they say the bugs are just terrible things and we should kill them all with antibiotics. No.

DrSG:

Everybody says it’s a new dawn and bugs are the most important thing that we have to know about. They make seratonin and they do all these things with the immune system, so the GI literature is just exploding with how important they are and that the bugs are in the organ of our body. At the time not having these ideas, they seem quite foreign, but to the current population that’s interested in health and wellness, they don’t seem weird. In 2016 when I wrote that article, it wasn’t something that I felt real comfortable about, but now nobody finds it weird. Then you put it together — once I have my microbiome back, I now have the organ of my body that does a million other things.

DrSG:

What does that mean if I have a sleep disorder? What that means is you’ll get your D up and it will play a small role in making acetylcholine. Your D and your B-50 together will bring back your microbiome and then you’ll actually be starting day one of the fourth month with a human being who has all the organs of their body that they were supposed to have; that they needed to generate normal sleep. That does not mean that all your repair is done. It means you now have all these bugs that are actually probably responsible for absorbing all sorts of small charged ions, like iron and iodine and sulfur and all these other things. They were also showing in the natural medicine world, like what you’re in, that those are also all screwed up because the microbiome probably plays a large role. We now have this concept that it’s a two way conversation; that the microbiome actually responds to what our stores are.

DrSG:

That idea is now being touted by lots of other people, so it doesn’t sound weird when I say, “Oh, you’re just starting off. You haven’t finished anything. You just started.” Now you have this organ in the body that plays a role in making endocannabinoids. It plays a huge role in talking back and forth to the nervous system. And now the next year that you’re doing things, either with your diet or with exercise or even with other vitamins, you have to be very careful with the dosing of the vitamins once your bugs are back. It turns out that if you try to take B-50 into month four or five, most people (including me) got sleep interruption and pain because we then had two sources. Our bugs came back and we were still taking the pill. That means her warning about large dose B’s is really important. You must be willing to say: What does my body say in this moment about this level of this replacement? It’s not what’s said in the literature — it’s extra… it’ll never hurt yourself. That is absolutely not true.

DrMR:

Let me paint an avatar that represents probably a fair extent of our audience and see how you’d recommend they proceed from here. Or at least as best you’re able. I know everyone’s individual and we have to work them up and give them personalized recommendations, but much of our audience has their diet fairly well dialed in; where they’re probably doing some type of a loose iteration of a paleo diet or something somewhat similar where they’re focusing on high-quality, unprocessed foods. What the nuances are, we’ll just leave it there. And they’re likely exercising… getting time in the sun… using some supplemental probiotics and perhaps also prebiotics along with that… meditating. I think we have a cohort here that has gotten a lot of the initial steps out of the way. For people who are still struggling with sleep, to whatever extent you can offer a broad brush recommendation, is something like the B-100 supplement where you think they should start? What advice would you give people to try to start moving their sleep in a better direction if they’re still suffering?

Sleep Advice & Supplement Dosing

DrSG:

Excellent, beautifully formulated question. My first recommendation is you go to my website (https://drgominak.com/) and you buy the workbook. First you learn about this. If you think that you’ve done everything that Michael just talked about, and you’re still not successful, that’s really important because maybe those things would’ve moved you all the way and you don’t need to mess around with this other stuff. This was a lot of my original population. If you feel like you’re already doing the diet, the exercise, you’re very interested in health and wellness, and you’ve done it, but it hasn’t worked to the extent that other people report, then this is a pretty complex program. You really have to be able to piece together (especially if you’re into supplements already) — How do I know if I’ve already brought back my microbiome? If you’ve been doing D for five years and your D level is 55 (it’s not exactly 60, but it’s 55) and you have records for the last three years that show it’s 55 and you happen to take B-50 (or in fact you’re taking B-50 now), it turns out that your story is slightly different. Your sleep is terrible now because you are actually on too much B’s and you didn’t follow this program that I only stumbled into by accident.

DrSG:

It doesn’t fall to anybody. Most of the people that I see that have been to a naturopath got better on a combination of D and B-100, and then they pretty quickly got worse again, but the same things resulted. It turns out that B5 and D, when they’re too high and too low, feel exactly the same. That means really being able to tease that out as an individual… “I saw this naturopath five months ago… my sleep got better… my pain got better… now, five months later, I’m worse again…” The piece you don’t know is you had to stop that B-100 because now you have two sources and you’re back into bad pain in your feet and back pain and you wake up in the middle of the night and your anxiety is back. There’s no way a single individual can ever figure that out because it feels the same and it changes very slowly.

DrSG:

Your population is a little different because they’re already interested in this stuff. Anybody who has already been delving into the vitamins has to understand this a little bit more in depth. They have to understand that B5 is an extremely powerful chemical. If your body needs 10 milligrams, then it will feel great and your sleep will be great. If it needs 15, it’ll be totally different. That just doesn’t make any sense from the point of view of even a person like me. I took 500 milligrams at the beginning and my head didn’t blow off. All I got was restless legs. A year and a half later, I couldn’t really do anything because my butt pain was back and it went away with 10 milligrams. That was totally bizarre.

DrMR:

One quick interjection here. Much of this resonates deeply with me and I really appreciate it. The highly nuanced and oscillatory degree of the B vitamin supplementation — that to me seems like there might be something there that hasn’t yet been flushed out. If I push back on that concept, what’s your response and what’s your defense?

DrSG:

I don’t think we know very much about the B’s. The part that I have on my website is the part that I know well; that I think I’ve seen clinically enough to talk about. But there are many, many things that the naturopaths know about the other B’s that I don’t know. I have very limited knowledge. What I know about is like a little tiny piece of the pie. What that means is (and the reason why I like the way you phrase your original question), I think what the naturopaths are doing is the right stuff. If it works for you, then you don’t need mine, but if it didn’t work or it worked for a while and then it went away, then you might want to look into this and incorporate this belief system in it. That doesn’t mean my answer is a better answer. Maybe that means that I need to do this and see if I get this result. My picture of how my stuff fits into the naturopath world is that we start with this as a basic foundation piece. We then think through what I’ve learned as a naturopath and then apply this piece. You’re going to use it differently than I would as an MD or a sleep dentist would.

DrMR:

Well, sure, but what I’m trying to derive here is (because most of this fully resonates and I’m right there with you), is it fair to say that as someone works with their system and improves their health, there’s this general linearity in needing a lower dose of B vitamins over time? That would make some intuitive sense to me. If we go much beyond that, where there’s this high level of variation, that’s where I start wondering how much of this is placebo/nocebo. And it gets harder, I think.

DrSG:

Let me just tell you one observation that I think is strong enough that I put it in the workbook. That doesn’t mean that this is the only set of variables. There was this very weird set of clinical observations, which is why I have a website. The D made a big difference. Getting on the B-100 or B-50 made a big difference. Almost everyone, after they stopped the B-50, if they slept better and only if they slept better, three to five months after they slept better and stopped the B-50, their sleep fell apart and their pain came back. And there’s a whole series of interviews where I talk about what happened to me and what happened to my patients. But ultimately, there’s a very unique clinical event that happens three to six months after you stop the B-50, if you sleep better. So there’s a suggestion that your brain has to go through a phase saying “I’ve actually done my nightly maintenance list every single night and then it says, but what about all the deferred repairs that I didn’t get done over the first 10 years of you not sleeping?” And it starts to ask for more B5.

DrMR:

This makes sense to me. Another way I could even rationalize that would be that the intervention was sufficient enough to lead to healing for a term, but the person had a regression. It’s almost like someone where you do a lot of work to improve their IBS. They’re doing great for a number of months. They have a regression and they need a little bit of touch-up care. I’m with you there if I’m interpreting that correctly.

DrSG:

Let me just add one more thing. Almost everybody, when they start to fail at that point, if they had GI tract complaints before, they get GI tract complaints back. Our tendency is to think that my bugs are bad again, but they’re not. In that phase, it’s the nervous system that runs the sleep, the nervous system that runs the gut (which is the same) and runs the belly parts (like bladder) and runs anxiety. The autonomic nervous system uses acetylcholine and it goes through this weird phase that starts about three months after you stop B-50 and ends six to eight months later. There’s a finite period of time. D is playing a role in that because it doesn’t happen if you just play around with the B’s. You can take B-100 for five years. Lots of people have, and it doesn’t happen.

DrSG:

There’s something that D is doing that is changing the expression of some protein or some system that then goes through a six to eight month period where it wants more B’s. And then you have to come completely off the multivitamin. I had people who’ve always been taking a multivitamin that finally got pain from five milligrams of B5 in the multivitamin. That doesn’t mean that everything else you know about thiamin or riboflavin or niacin or ALA… I’ve learned so much about ALA and things like choline from the people who’ve already gone through my program, but weren’t completely fixed. Every single one of these B’s is attached to other ones. We haven’t mentioned B12, but it’s a separate thing. B12 deficiency actually always comes from D deficiency. It has to be treated differently. When, and if, you guys start to look into this stuff, it’s not that it’s different than what you’re doing.

DrSG:

It’s that it’s a different piece. It just gives you a slightly different way of looking at it so that the timing of what you do with your client or your patient depends on what they’ve done in the past and what the current complaints are. But that complaint from the GI tract at that point doesn’t mean the bugs are gone. It means that the nervous system of the GI tract is acting up because the parasympathetic runs rest and digest also. And the reason it’s called rest and digest is because it makes you calm in the day. Acetylcholine calms you, makes you focused, it allows you to sleep at night, and it also runs the GI tract.

DrMR:

Hi everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic – The Ruscio Institute for Functional Medicine – and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. We also offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFMR – The Future of Functional Medicine Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

DrMR:

To pivot just for a moment – I do want to set this lure in case we do a part two. There is the other aspect of this, which is airway health. I’m not sure if you’re doing anything with, or you were doing anything with, these newer generation home sleep tests; looking at apneic events as compared to respiratory distress events and mapping that onto recommendations for, let’s say, myofunctional therapy or mandibular advancement. Is this something you’ve done a delve into?

The Sensory System of the Mouth & Airway Health

DrSG:

Thrilling, Michael! You have the entire picture. I came out of neurology thinking, incorrectly, that I had answered every question that needed to be answered. Luckily for me, the dentist picked up my stuff. The MD’s could give a shit. Still, the dentists were really interested. So, I went to all these dental conventions, gave lectures, and sat in their lectures. And at the beginning I thought, “Change in the lower face? No way. That’s a bunch of bologna.” No. They’re absolutely right. It’s fascinating to me that we have separated what the dentist does as though the head is not part of the whole body. We could do a whole other hour on what the dentists have taught me about how the sensory system of the mouth and throat talks directly to the brain stem. When the dentists or the myofunctional therapists have their hands in the mouth, there are purposefully direct sensory links into the brain stem because that part of the brain is what’s running the ability to know if I just stop breathing.

DrSG:

When we’re about the airway, the second piece is: How does the brain know if I just stopped breathing? There has to be a messenger. All the dentists are teaching me about the glossopharyngeal nerve and that turns up the vagus… the third branch of the trigeminal and that turns up the sympathetic. And as I’m watching these lectures, I realize they’ve got their hands in the system that directly moves the autonomic nervous system. You put in a mouthpiece and it stimulates the glossopharyngeal and tics and Tourette Syndrome goes immediately away in two minutes. I have another two hours about that.

DrSG:

I didn’t even know what a myofunctional therapist was and now I think they’re like gods. They are doing things that change the outcome. Everything I’m talking about can’t be used alone without the anatomic piece. They are intertwined, as is our actual anatomy. Trying to prevent things from happening in children is also about trying to have a child that always can breathe through their nose while they’re sleeping so their functional development of their face becomes normal. That’s all been generated by the myofunctional therapist and the dentist and the sleep dentist and all the things that these people are doing, which is completely brilliant.

DrMR:

It is. I did one interview. I think the first interview may have been Kevin Boyd on this topic and that was the crack in the door. And then as you walk through the door, you see there is a whole community of people hard at work, trying to stop dentistry and orthodontics from using these contracting devices and calling attention to how important the airway is. You then cross reference and think some of this is super speculative and there’s not good evidence. But then you see mandibular advancement devices and you could argue they work better than CPAP because it reduces cardiovascular episodes where a CPAP doesn’t. And there’s a lot here. Now I know what our part two could be on.

DrSG:

I would claim the same thing. For each one of us who is a good clinician, it’s very difficult. Medicine has been so changed by the pharmaceutical industry and they’ve used these evidence-based medicine tags to try to embarrass and make us feel less than when we’re having clinical observations. We have to fight against that because every single person who is a clinician doesn’t keep doing the same thing when it doesn’t work. And the biology is always telling the truth. The only truth in the room is always what the patient says. That means these dentists see things happen when they do these things in the mouth with growth appliances or with mandibular advancement. They’re not just talking about it because they want to advance their own ego. They’ve seen amazing things happen. Then they have questions about “…these three people got better and this person didn’t…” That means when I start to have partial success in my program, I have to remember: Have you seen the ENT to make sure you can breathe through your nose? Have you seen a sleep dentist? Have you actually ever had anybody evaluate the anatomy of your airway? And each one of us that’s in our little subspecialty, whether it’s airway or brain, needs all the other ones.

DrMR:

I think you’re a bit more charitable with your read on some of the field. Unfortunately, and this is probably partially biased by what I see walking in the door, but in addition to some wonderful data from clinical anecdotes, there’s also those who just look at everyone as a nail because they have a hammer. People get incorrectly diagnosed and there’s this dogma. I think there’s this balance point we need to get. I agree that there is this snooty evidence-based crowd that shits on anyone who doesn’t have a meta-analysis to support what they’re doing.

DrSG:

Spare me the meta-analysis, please.

DrMR:

I think there’s a lot of value in meta-analyses, but when you get this pompousness and arrogance… Ironically, a lot of the people who make these remarks…”Well, there’s no good evidence for X, Y, Z…” When you actually probe into a deeper conversation with them, you see they’re actually not very well read. That I think needs to stop — that medical arrogance… that science arrogance. On the other side of the coin, there are also the providers who throw all caution to the wind and don’t try to have any scientific mooring or evaluate if what they’re doing is actually helpful or if it’s just confirmation bias and placebo effect. We need to integrate both of these – get away from the arrogance, but also be a bit more willing to challenge if what we’re doing is actually working well.

DrSG:

I think that’s very well said. I actually feel that I am completely guilty. That’s what all my colleagues said — “To a hammer, everything looks like a nail…” — because all I talked about was sleep and then all I talked about was D. It’s really me working with the dentist and seeing that each one of them has his or her own intervention in trying to achieve the same thing and realizing we could look at that at different way. If this approach doesn’t work, then they can go see Michael Ruscio or they can go see Kevin Boyd. We can see it in a slightly different way and have better success.

DrMR:

Sure. It’s exciting because there’s a lot of opportunity in the field to better help people and better learn and better explore. Sleep is definitely one of those areas that I’m quite excited about. Would you remind people of your website and/or wherever else you would like them to go if they wanted to connect with you and/or learn more about you?

DrSG:

Thank you, Michael. It’s drgominak.com. I would recommend that you read a little bit. If you decide you want to take this on, don’t try to do it without the workbook. That’s down in the middle of the homepage. We’re also adding question and answer sections. If you’ve bought the workbook and you’re going to try the RightSleep program, I’m now trying to make it available to you to have direct exposure to me. I also do coaching sessions that are either a year or a six month commitment if you’ve had a very complex, long-term sleep problem. I’m available for individual coaching. And I also have videos that are dedicated to pregnancy, fertility, and doing this program with a newborn, as well as a set of videos about how to do this with kids – how to adjust the dosing and that sort of thing.

DrMR:

Great. Thank you for your dedication to sleep. You’ve opened my eyes to a few things here regarding vitamin D and the vitamin B family.

DrSG:

I love that – family.

DrMR:

… and the importance for sleep. So, thank you for that. I really appreciate the conversation and hopefully we’ll have another one soon.

DrSG:

Thanks, Michael.

Outro:

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