Fatigue & insomnia

Finding peace for your legs — a simple approach to restless legs syndrome

Help for women with insomnia due to restless legs syndrome (RLS) and periodic limb movements in sleep (PLMS)

by Marcelle Pick, OB/GYN NP

Topics addressed in this article:

• What is restless legs syndrome?
• Restless legs syndrome, the brain, and sleep
• The elusive restless legs syndrome “gene” and other causes
• A recipe for restful legs — iron, folate, and magnesium
• Your path to rest

My patients with restless legs syndrome (RLS) describe the feeling to me as the “creepy crawlies.” The persistent tingling leaves them feeling like they just have to move. And what’s worse is that this urge to move can make it impossible to sleep, relax, or even sit still. Though it’s reported twice as often by women than men, the truth is, I don’t see very many patients with restless legs syndrome. But those I do see have oftentimes struggled with it for a long time without help. The good news is, we’ve been very successful at helping our patients overcome their RLS or period limb movement and get back to sleep — without using drugs.

For many years, RLS and the associated periodic limb movements in sleep (PLMS) were poorly understood, underdiagnosed, and undertreated. Conventional medicine had few answers for people with restless legs syndrome, and some experts even questioned the condition altogether. But you may have seen recently that there are new prescription drugs on the market, such as Requip and Mirapex, that drug companies are spending millions to market to people with RLS.

Though these medications have definitely helped severe cases, many women don’t know they’ve been linked with fatigue and some bizarre side effects like hypersexuality, pathological gambling, and compulsive eating. I know severe RLS symptoms can truly impact your quality of life, but you don’t have to turn to a prescription drug or go on suffering. There is a natural approach to RLS that focuses on finding the root causes of your symptoms.

New research is looking more closely at restless legs syndrome and periodic limb movements in sleep, and it’s finding that there is a significant role for nutrition in their treatment. Let’s take a closer look, so you can reach restfulness in your legs — and whole being — naturally.

What is restless legs syndrome?

For those women who have experienced the symptoms of restless legs syndrome, the sensation of needing to move their legs — and sometimes arms — can be overwhelming. It keeps them up at night, pacing, tossing and turning in bed, or rubbing their legs to ease the tugging, electric current-like feeling flowing through their limbs. And it isn’t just the person with RLS who loses sleep — oftentimes partners are kept awake at night as well. Diagnosis of RLS is generally based on a patient’s subjective feeling and symptoms. You may recognize yourself in these diagnostic criteria:

• You feel an urge to move your limbs (especially your legs), usually accompanied by “pins and needles” sensations.
• Symptoms come on or increase while at rest.
• Relief comes almost immediately with movement.
• Symptoms are generally worse at night.

If you are conscious of all four of the above, chances are you have RLS.

One symptom that not all RLS patients experience — sleep disturbance — is the number-one reason people seek help, and the reason why RLS is classified as a sleep disorder. This is where periodic limb movements in sleep (PLMS) come in. When the majority of people with RLS go to sleep, their feet and legs begin to move repetitively every half-minute or so, lasting around 1–3 seconds. For some, the movements are large enough to wake them up. Others are completely unaware of all this activity while sleeping, but wake up feeling tired each morning. For this reason, diagnosis of PLMS is generally confirmed through a sleep study.

There are two main forms of restless legs syndrome: primary RLS, where there is a clear familial (genetic) component; and secondary RLS, which is acquired. Research tells us that both forms are associated with low levels of the hormonal neurotransmitter known as dopamine. Primary restless legs syndrome may stem from an inherited glitch in the way we metabolize dopamine in the body and brain, while secondary RLS seems to be linked more to altered iron metabolism — iron is a precursor to dopamine. (See box, “Who gets RLS?”)

Dopamine is a key messenger in the brain that influences behavior, thinking, mood, sleep and movement among other things in the body. Levels of dopamine that are below normal can leave us with less control over our limbs and may trigger the urge to move. An extreme inadequacy of dopamine can cause the uncontrolled tremors and movements associated with Parkinson’s disease.

Restless legs syndrome, the brain, and sleep

The biggest complaints I hear from my patients with RLS relate to lack of sleep. What’s interesting is that the neurotransmitter dopamine has a timed pattern of release that mirrors our circadian rhythms. It’s highest in the morning and lowest in the late evening, causing those women with low levels to have greater symptoms of RLS during the nighttime hours. Sadly, this leads to sleep disturbance in four out of five people who have RLS.

About 80% of people who have RLS also experience the periodic limb movements in sleep,described above (PLMS, aka PLMD). This can cause them to wake themselves up (and, again, their partners, too) by jerking, kicking, and shaking their arms and legs during sleep.

The constant movement, night-waking, or inability to fall asleep in the first place can really add up, leading to several lost hours of restorative sleep per night. We all know what one night of poor sleep can do to our daytime mood and performance — and repeated bouts of insomnia for a span of even a few days makes it that much worse. Just think about how hard it is for new mothers to function before their babies start sleeping through the night! But when insomnia becomes a pattern that lasts not just night after night, but year after year, many aspects of our health can suffer, including our immunity, cognitive function, stress response, mood regulation, and many other issues that profoundly impact our quality of life.

In fact, how well we sleep affects our whole outlook on life. A 2003 survey conducted at a sleep disorder clinic found that patients with chronic sleep disorders (including PLMS and RLS) had more than a 50% chance of suffering from some form of depression. What’s more, use of certain antidepressants, including selective serotonin reuptake inhibitors (SSRI’s), can worsen PLMS! This makes sense; though we don’t understand all the details, we know the circadian rhythm of our natural sleep–wake cycle is modulated by serotonin and other mood-regulating neurotransmitters in the brain.

The elusive “restless legs syndrome gene” and other causes

About a year or so ago, you may have read the headlines proclaiming the discovery of the gene for restless legs syndrome. This is misleading, because the team of geneticists involved was evaluating people with RLS who also happen to experience the related condition, periodic limb movement in sleep (PLMS), as described above. And what they identified was a genetic variant connected to PLMS, not RLS.

In other words, the genetic link they found was only present in those who had PLMS, not in the 20% or so of RLS sufferers who don’t have PLMS. It’s interesting to note that some of the people designing and writing up these studies happen to be paid consultants to the companies manufacturing RLS drugs. That’s just something to keep in mind when you read medication ads or blogs suggesting that you, too, could be one of many who unknowingly carry the “risky” gene for RLS.

Genetics assuredly do play a role in many women who suffer from restless legs syndrome — even if we haven’t precisely labeled all the genes. As I mentioned above, primary RLS can be passed down from your parents. Studies suggest it shows up in about half of first-degree relatives with RLS.

I’ve also seen that several lifestyle factors can lead to or exacerbate restless legs syndrome, including frequent caffeine use, smoking, and drinking excessive alcohol. As noted above, SSRI’s and tricyclic antidepressants can also contribute to RLS — as well as any medication that can counteract our ability to regulate dopamine activity in the brain. But in my experience, whether you’ve inherited restless legs syndrome or acquired it, you can influence your dopamine production and quell the restlessness in your legs through focused nutrition.

A recipe for restful legs — iron, folate, and magnesium

Many conventional practitioners are prescribing pharmaceutical medications for severe RLS sufferers. These drugs work by forcing the body to make dopamine more available to its receptors. And they are effective in calming symptoms and helping with sleep. But, as I mentioned before, these drugs (originally developed and ordinarily used for Parkinson’s disease) can have serious side effects, and they don’t address the root of the problem. A longer-lasting and gentler approach to restless legs syndrome involves using needed nutrients — or key “ingredients” — to help your body make more of its own dopamine.

If we look at the way dopamine is produced in the body, we can see that both iron and folate are key players in its formation. Iron is necessary for the production of an enzyme that is responsible for converting dopamine’s precursor, L-tyrosine, into dopamine, while folate comes in further upstream to increase a precursor to this enzyme. I’ve noticed that several women patients who are suffering from RLS have too little iron or not enough folate in their diets. Iron deficiency is one of the most commonly associated conditions we see relating to RLS.

Keep in mind that the following suggestions may not work for everyone. If you’ve tried supplementing with iron and folate and do not notice a difference, you may want to talk to your practitioner about whether you could have a problem metabolizing either or both of these nutrients.

Iron. If you suspect that your iron may be low, have your practitioner test iron. If your serum ferritin is less than 50 ng/mL or your iron saturation is less than 16%, you would most likely benefit from increasing your iron intake.

But if these levels are normal, or even high, as in a disorder known as hemochromatosis, there may be an issue with how iron is transported from your blood to your brain. In that case, work with your practitioner to determine the root cause before using an iron supplement.

We don’t include iron in our Essential Nutrients formulation because most women 35 and older do not need supplemental iron, and it is not healthy to let levels build up too high. It’s preferable to confirm a woman needs it through simple laboratory testing.

If you know your serum iron is low, you can increase your iron by eating more iron-rich foods or by taking an oral iron supplement. I’ve seen women make great progress by taking 50-65 mg of elemental iron daily with 500 mg of vitamin C. Some women give up on oral iron due to digestive upset or constipation. If you’re looking for a good iron supplement, I’ve found Thorne iron products to be very well-tolerated and effective in my patients. I tell my patients to avoid taking iron when their stomach is empty, and also suggest they take calcium separately from iron supplements or iron-rich foods, as studies indicate calcium can inhibit iron absorption. Talk to your practitioner about the best approach for your situation, and be sure to have your iron tested periodically (once or twice a year) while using supplements.

Folate. Many women with digestive disorders or nutritional deficiencies may suffer from low folate levels, making them more prone to RLS. Pregnant women require eight to ten times more folate than those who aren’t pregnant, which could help explain why RLS is more common in pregnancy. A folate deficiency can sometimes lead to depression, fatigue, and lower limb numbness or tingling along with restless leg syndrome. Depending on your individual case, supplementing with 1–30 mg of folic acid per day may help relieve symptoms of RLS.

If you find that added folic acid isn’t helping, please don’t immediately assume it’s because you didn’t need folic acid. The issue may be that you have difficulty metabolizing it. Some people are less efficient at converting folic acid into its active form in the body. This is due to a common genetic variant present in anywhere from 1–40% of people, depending on ethnicity and other factors. This inherited gene mutation compromises conversion of dietary folic acid into its major bioactive form (5–methyltetrahydrofolate) in the body. This issue can be treated with supplementation, so if regular folate doesn’t work for you, try a folic acid supplement with 5-methyl in it. For best results, you may need to work with someone familiar with this aspect of nutrigenomics — the study of molecular relationships between nutrition and the response of genes — such as a functional medicine practitioner.

Magnesium. Researchers who have studied the relationship between RLS and magnesium have discovered low blood levels in many RLS sufferers, where the magnesium in the body may be too aggressively transported from blood serum to cerebrospinal fluid. Magnesium helps with muscle contraction and healthy conduction of nerve impulses, and I’ve seen many patients who experience almost immediate relief from their RLS within days of increasing their magnesium intake. Magnesium may also be interacting with the iron transport system and with dopamine and opioid receptors to affect RLS symptoms. So check your multivitamin to make sure it includes adequate magnesium. I would suggest 400–600 mg daily, taken at night before bed. You can also include more magnesium-rich foods rich in your diet. See the chart to your left for some good dietary sources of magnesium.

Your path to rest

Over the years I’ve seen women make major changes by examining their physical concerns in the context of their emotions. It’s amazing how much you can learn about your physical state through an honest and loving look at your emotional well-being. When it comes to restless legs syndrome, I often try talking with women to discover what might be making them restless in their lives. Could it be time to take action in a relationship, in your job, or with your health? It never hurts to step back and take a broader look at your life, and how restlessness in your legs may inform your inner well-being.

I know restless legs syndrome can significantly interrupt your life, but recent science has shown us that working with the nature of your body with nutritional supplementation can offer safe and effective solutions. With a better understanding of how imbalances in dopamine can lead to RLS and an idea of how you view this issue in the greater context of your life, you hold the knowledge to help yourself. The challenge comes with finding what your unique body needs and giving it just that. Collaborate with your practitioners to better understand the root cause of your symptoms, and use your body’s own wisdom to navigate a path to a restful body, mind and soul. I promise you’ll find the results rewarding.

Related to this article:

References & further reading on restless leg syndrome

 

Original Publication Date: 09/15/2008
Last Modified: 02/16/2010
Principal Author: Marcelle Pick, OB/GYN NP