Sleep & IBD disease activity

You may notice that as stress increases in your life, so does your disease activity, or vice-versa: an increase in disease activity can lead to more stress.

By Leslie Ann Berg, MSPH 

We’ve found that in order to make actionable, lasting behavioral change, knowing the scientific explanation for how and why something is occurring can be a potent stimulus for action. So, let’s dig into the research.

Following strong anecdotal evidence in IBD patients, scientists began conducting research to see if there was actually an association between psychological stress levels and IBD disease activity. Studies based on symptom reporting revealed that mood disorders (namely depression and anxiety) can lead to increased inflammation and a heightened risk for IBD, as well as worsening disease activity in those who already have the disease.

While the brain can affect the gut, scientists have also uncovered ways that the gut affects the brain. Researchers have identified gut-brain signaling that proves inflammation in the intestines alters brain function, and in turn, negatively influences behavior – disrupting circadian rhythm, uncovering mood disorders, and altering appetite. Studies also show that psychological symptoms and IBD symptoms go hand in hand – as one increases in severity, so does the other.

It’s evident that not only can depression and other mood/behavior disorders lead to an increase in IBD disease activity, but also the opposite is true – IBD can lead to an increase in mood disorder symptoms. But how? The mechanism is through the gut-brain axis. The gut-brain axis describes the bidirectional relationship between the gut and the brain – the two organs communicate constantly with each other, sharing neurological, hormonal, and immune signaling. This relationship is strong and very real and explains why gut disorders affect the brain (as well as brain-related functions like mood, appetite, sleep, and behavior) and why things going on in the brain can affect the gut. If you’re looking to get your IBD under control and into long-term remission, one of the most helpful tactics is to manage your psychological stress. Managing your psychological stress means – in a very direct way – managing your IBD.

But how do I do this, you might ask? Because, as most of us know, managing stress isn’t so easy.

A 2020 review looked at studies investigating the strong link between psychological stress and IBD and concluded that a holistic approach to managing IBD is vital for patients to keep their psychological stress in check. Researchers who conducted the review study recommended implementing lifestyle interventions focusing on three main areas:

1. Avoiding sleep deprivation
2. Optimizing nutrition
3. Monitoring and managing mood disorders

We couldn’t agree more. Modifying your lifestyle to improve your disease is the best way to encourage long term remission. While optimizing nutrition and managing your existing psychological health are important points and areas we’ll spend a lot of time talking about on this site, sleep is an under-addressed issue that we think needs a lot more attention. In fact, a study published this year in Current Gastroenterology Reports reviewed what we know about sleep in the IBD adult population and concluded that poor sleep is an unrecognized but incredibly important “extra-intestinal manifestation” of IBD. A study presented at Digestive Disease Week 2020 found that within the first 6 months of diagnosis, approximately 26% of IBD patients developed “new onset fatigue”, and fatigue was strongly linked to a prior diagnosis of depression, anxiety, and sleep disorders. Additional studies have found the following relationships between IBD and sleep:

• Poor sleep in IBD patients is independently linked to depression and a low quality of life
• Lighter sleep has been observed in IBD patients as well as decreased rapid eye movements
• IBD patients report circadian misalignment (sleeping, waking, and eating at times outside of the regular rhythm), which has been associated with more aggressive disease characteristics
• Sleep disturbances are linked to intestinal inflammation and increased immune response
• Poor sleep is a marker for disease activity in subclinical patients
• Overall, IBD patients have reported less sleep (one study found that adults with IBD averaged 4.5 hours of sleep per night), disturbed sleep, and circadian misalignment

The relationship between IBD and sleep is bidirectional – sleep impacts disease activity and disease activity impacts sleep – so coming up with strategies to improve sleep quality and realign the circadian rhythm is paramount for achieving psychological health and long-term remission.

TAKE ACTION! As you work to manage psychological stress in your daily life, make sleep a #1 priority. Let nothing (in your power, of course) get between you and a good night’s sleep. To help get you there, we recommend the following:

• Consider behavioral therapy. A 2020 study found that just 4 weeks of behavioral therapy for sleep significantly improved sleep quality in IBD patients. After 8 weeks, improvements in fatigue, anxiety, and depressive symptoms were also observed. When compared to a group who went through the same behavioral therapy and also received a sleep aid medication, the group who received no medication and therapy only had the same results as the medication group. Results show that brief behavioral therapy alone can result in huge impacts on sleep.  
• Consult your medicine cabinet – Some IBD medications may negatively impact sleep, including steroids, which can make falling asleep challenging, as well as other medications that can cause insomnia and night sweats. Talking to your doctor about your medications and how they affect your sleep is important, including discussions of alternate dosing schedules or ideally, tapering off them completely when possible.
• Shift the bulk of your calories to earlier in the day – Breakfast like a queen (or king), lunch like a princess (or prince), dinner like a pauper… and consume nothing after 8pm. Your stomach actually has a bedtime and stomach contractility decreases markedly after dark, so stopping eating at sunset, or shortly thereafter, can give your digestion a rest and minimize symptoms before bed and throughout the night.
• Relax – No matter what stresses you’re suffering from, whether it’s the grind of daily life or the stress of having a chronic disease, (or both!), implementing relaxation methods an hour or so before bed can be incredibly helpful for falling asleep faster and staying asleep longer. Try a calming herbal tea (like chamomile or lavender), take a warm bath or shower, and/or try deep breathing, meditation, or a short and relaxing yoga sequence. Be sure to dim the lights in your home and avoid anything that knowingly induces stress in the hour before getting into bed.
• Be mindful of what you eat in the second half of the day (avoid spicy/fatty foods) – While it’s important to always be mindful of what you’re eating, paying special attention to the second half of your day can help prevent GI symptoms at night. Some foods that can be problematic include very spicy, fatty, or processed foods, as well as gluten and dairy. Focus on veggie-centric smaller meals as you get closer to bedtime.
• Exercise – Moving your body aids both gut health and sleep, and is one of the best ways to encourage quality sleep. Getting a minimum of 20 to 30 minutes of exercise each day, preferably outside, can allow your body and mind to rest more soundly at night – and it’s also a great stress reliever. 
• Avoid smoking and alcohol – Both smoking and alcohol have been linked to disturbed sleep. 
• Get outside – Exposure to natural light can help you get better sleep and improves circadian alignment. In fact, even being inside but next to a window with lots of natural light can make a big difference. A study conducted in office workers found that those working near a window experienced better sleep quality than those who worked in a windowless environment. We recommend spending time at least 30 minutes outside daily. If this isn’t always possible, spend time exposed to natural light indoors, and open windows in your home or car to let fresh air in, which is good for sleep and your immune system.
• Stop screen-time an hour before bed and keep your phone out of the bedroom. The blue light of electronic screens interferes with your ability to fall asleep quickly and can have lasting disruptive effects on sleep throughout the night.

Lastly, remind yourself that not every night will be a good night’s sleep, especially if you’re experiencing a flare-up. But the more you implement the above steps day in and day out, the more likely you are to get good sleep most nights, which will improve your psychological, immune and gut health, and have a positive impact on your IBD.

Read Sleep & IBD Disease Activity.