DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7

LVL 1 Identify as a professional sleeper

LVL 2 Consistent bedtime

LVL 3 Wind-down routine

LVL 4 Eat early

LVL 5 Avoid stimulants (alcohol, caffeine)

LVL 6 Regulate evening light

LVL 7 Optimal temperature

LVL 8 Peaceful sleep environment

LVL 9 Morning light

LVL 10 Gather data

 Improving and Maintaining
Healthy Sleep Habits
What is insomnia?
When people are not able to fall asleep or remain asleep, they suffer from insomnia. Many different
factors can contribute to sleep problems, including a change in daily routine. This can happen when
you travel or have a change in work hours. It can also be caused when noise, a change in eating or
exercise habits, leisure activities, or relationship conflicts get in the way of good sleep. Insomnia may
be one of the first symptoms to appear when someone has anxiety or depression; fortunately, it often
improves early on when those conditions are addressed. Difficulty falling asleep can be related to
anxiety and having your mind race from thought to thought. Waking up too early can be related to low
levels of some hormones, particularly if a person struggles with anxiety, depression, and other mood
concerns.1-5

Why is lack of sleep a problem?

Sleep is essential to good health. When people sleep, their tissues heal, grow, and repair
themselves. Sleep helps the body make the right levels of important hormones including:
• Cortisol - released every day to help you wake up in the morning. It is also released during
times of stress.
• Melatonin - the circadian rhythm hormone. How much is released by your brain is based on
time of day and light levels. It is released in the brain to help you prepare for sleep.
• Gamma-Aminobutyric acid (GABA) - helps you relax and allows nerve cells to
communicate.
• Growth Hormone - a hormone that helps cells grow and repair damage.1,4

Hormones require time to balance out overnight during sleep. People are more likely to be tired,
irritable, anxious and depressed if they do not get enough sleep. Your brain needs sleep to wire (and
rewire) connections between nerve cells. This makes it so you can store new memories and learn.
Good sleep is also linked to better concentration. In addition, people who do not sleep well are more
likely to have pain, get sick easily, and have a hard time managing other diseases.1 People with
insomnia are much more likely to be involved in car accidents and perform poorly in athletic
competitions.6, 7

What does a healthy sleep/wake pattern look like?

Most adults from age 18 to 65 need about 7 to 9 hours of restful sleep. Older adults may need a little
less sleep, only about 7 to 8 hours per night. Children need much more sleep than adults. The
amount depends on their age. See the National Sleep Foundation website for guidelines based on
age: https://www.sleepfoundation.org/press-release/national-sleep-foundation-recommends-new-
sleep-times.8

Improving and Maintaining

Healthy Sleep Habits
PATIENT HANDOUT 1
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
Here is an example of a normal sleep and wake cycle:

No matter what time a person plans to go to bed, the brain releases more melatonin, which makes
you sleepy, when it gets dark outside.1,2 This helps most people sleep at night and stay awake during
the day. If a person is around bright lights at night, the brain will not release very much melatonin.
Bright light sources include indoor lights, as well as screens from a TV, computer, tablet, or phone.

Cortisol, a key stress hormone, goes down overnight, and then spikes in the morning to help get
your mind and body going for the day. It can also spike during the day if needed, or as a response to
stress. If you are stressed or unable to calm down in the evening, your cortisol level may stay high
and keep melatonin from being released in the brain. This is one reason why it is important to find
good ways to relax and manage stress during the day, so your daytime worries don’t keep you from
sleeping overnight.1,9

When we get older sleep is not as deep and it is common to wake up more often during the night.10
This is partly because our bodies make less melatonin and growth hormone, but also because of an
increased need to urinate at night. When we age, our brain makes less antidiuretic hormone, a
hormone that controls how much water is in our urine, especially at night. We produce more urine, so
we have to get up once or twice. If the signal comes more than once or twice, it is likely that we really
do NOT have to urinate, and can just try to go back to sleep.

Older age makes sleep apnea (stopping breathing in your sleep for short amounts of time) more
common. More than 2/3 of us have it.11 Treatment may consist of sleeping on your side, CPAP (air is
pushed into the nose by a machine to keep airflow going), or weight loss. Decreasing apnea can
improve memory, mood, and other areas of health.12 Restless legs are also common as we age.
Exercise during the day and pedaling a cycle before going to bed help. Another non-medical
treatment is a vibrating pad that slows and stops automatically when we are asleep. Talk with your
health care provider if you think you have apnea or restless legs.

Are there medications or supplements that can interfere with sleep?

There are several medicines, supplements, and substances that can get in the way of a good night’s
sleep. If you are taking any of these, it may be worth talking with your health care team to see if a
different medicine (or lower dose) could help improve your sleep.1,2, 14-16

Improving and Maintaining

Healthy Sleep Habits 2
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
 Medicines That Can Make It Hard To Sleep
or Limit How Much Melatonin Your Brain Lets Out at Night
• Amphetamines (methylphenidate, dextroamphetamine, other medicines to treat ADD or ADHD)
• Antidepressants (many classes—ask your health care team.)
• Asthma “rescue” inhalers (albuterol)
• Beta Blockers (atenolol, bisoprolol, carvedilol, labetalol, metoprolol, propranolol)
• Decongestants (phenylephrine, ephedrine)
• Diuretics (also called “water pills,” especially if taken at night: furosemide, torsemide,
bumetanide, metolazone, chlorthalidone, hydrochlorothiazide, spironolactone, triamterene)
• Histamine blockers (ranitidine, famotidine) and antihistamines (loratadine, fexofenadine,
cetirizine)
• Steroids (prednisone, prednisolone, betamethasone, cortisone, dexamethasone, fluticasone,
mometasone)
• Some thyroid replacement medicines (liothyronine, natural and other thyroid supplements
containing T3/tri-iodothyronine)

Supplements and Other Substances That May Make It Hard to Sleep

• Alcohol
• Caffeine (including coffee, green/black tea, sodas, energy drinks)
• Ginseng
• Nicotine, tobacco
• SAMe
• Weight loss supplements (Ma huang/ephedra, bitter orange)

What are some conditions that make insomnia worse?

Here are some medical conditions that can affect a person’s ability to get good sleep. If you have any
of these, it does not mean that you will never be able to sleep well. It does mean that you may need
to try several approaches (i.e., not only a medicine, or only supplements, etc.).1-5
• Anxiety, panic disorders, or PTSD
• Asthma, emphysema, COPD, and other lung diseases
• Depression
• Diseases of the central nervous system
• Heart failure
• Pain—any cause
• Restless leg syndrome/periodic limb movement disorder
• Sleep apnea
• Substance abuse

Improving and Maintaining

Healthy Sleep Habits 3
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
What is an integrative approach to treating insomnia?
The best way to improve your sleep habits is through a healthy lifestyle. This will raise your melatonin
at night and lower your cortisol/stress hormone in the evening (and help to keep it at a healthy level
all the time).1,4-5 It will help to balance out your body chemistry in many other ways as well.

Take steps to allow your own hormones to come into balance. Listed below are some of the most
effective changes you can make that will help you sleep both longer and better. Create a plan for
yourself. Change the habits that you can, one at a time. Do not try to do too many new things at
once!1,2, 4-5 What you do related to where and how you sleep is called your “sleep hygiene.”

Daytime
Recognize that you may not be able to do this alone. Research tells us that one of the most
helpful ways to fight insomnia (and restore a healthy sleep pattern) is to get insomnia-focused
counseling. This is called cognitive behavioral therapy for insomnia, or CBT-I. There is more
information about this below.
Regularly spend time outdoors or in bright light.
Exercise daily. There is good evidence that regular exercise improves restful sleep, and it
helps people feel more awake during the day.
Get up from bed at the same time each day, no matter what.
Keep a sleep diary. The National Sleep Foundation has an example of a good one on their
website: https://sleepfoundation.org/sleep-diary/SleepDiaryv6.pdf. Track your sleep, then talk
about this information with your health care team.
Eat fresh foods that are healthy for you.
Reduce stress. Find ways to regularly relax.

Nighttime
 Cut out bright lights an hour before bed. Dim inside lights, turn off the TV, or wear sunglasses
inside if others object to the low lighting.
 Develop a relaxing pre-bedtime routine, just before going to sleep. (Some ideas: listen to a
recording of guided imagery, practice a muscle relaxation exercise, massage tense muscles,
take a warm bath, etc.).
 As the temperature drops at night, our brain gets the signal that it is time to go to sleep. Turn
down the thermostat at night to lower the temperature. If drinking something hot, or taking a
hot bath or shower at night, do so at least an hour before bed to allow for a drop in body
temperature.
 Go to bed at the same time each day, no matter what.
 Keep the bedroom quiet when sleeping, or use a source of “white noise” (e.g., a fan, white
noise recordings).
 Keep the bedroom dark to facilitate sleep. (This increases production of melatonin, the sleep
hormone).
 Use your bed only for sleep and sex.
 Remove electrical devices from around your head when you sleep (e.g., radios, cell phones,
outlet connectors). Easy access to your phone or tablet may cause you to use it more in bed.
This can lower melatonin levels, both from the light of the screen, and any stress that may be
related to your interactions.

Improving and Maintaining

Healthy Sleep Habits 4
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
  Keep your feet and hands warm. Wear warm socks and/or mittens or gloves to bed if your feet
and hands tend to be cold.

What doesn’t work for my mind and body? (Remove barriers that may be
preventing a good night’s sleep) 1-5
• Try not to engage in stimulating activity just before bed, such as playing a competitive game,
watching something exciting on television, or having an important discussion with a loved one.
• Do not have caffeine in the evening (coffee, many teas, chocolate, soda, etc.).
• Avoid watching television, or using your phone/tablet in bed, and reading material that excites you
or wakes you up.
• Do not use alcohol to help you sleep. Alcohol disrupts your sleep cycle and suppresses REM
sleep, which can contribute to depression.
• Do not go to bed too hungry or too full.
• Stay away from daytime naps. If napping, subtract that time from night time sleep total.
• Do not try to command yourself to go to sleep or worry about not sleeping. This only makes your
mind and body more alert (and often upset). Research shows us that worrying about not sleeping
actually makes it harder to sleep! Remember that there are several safe remedies and
approaches to help you sleep.
• Try to steer clear of medicines, supplements, and substances that can make it difficult to get good
sleep.

What are some integrative things to try if I still can’t sleep?

Following are the top three most effective ways to fight insomnia:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I).

• The first step is to see what is really happening. Fill out a sleep diary for a week. An
example of a good one is available from the website of the National Sleep Foundation:
https://sleepfoundation.org/sleep-diary/SleepDiaryv6.pdf.
• The next steps involve visits with a trained counselor. CBT-I works because it takes into
account a person’s health, medicines, habits, thoughts and feelings, and helps to make a
sleep plan that is tailored just for you. It may include some of the sleep hygiene techniques
listed above. It often includes practicing relaxation techniques, setting specific sleep hours,
and using techniques that help calm the mind and reduce nighttime (and daytime) stress.
The counselor will also help set up a plan for what to do if sleep problems come back.
CBT-I is very safe, and the skills learned in this type of therapy can help you for years to
come.2,14

2. Melatonin supplements. A melatonin supplement helps boost the levels of the rest-related
hormone made in the brain. People generally do well starting at 1 mg each night. Many people do
better on smaller, rather than larger, doses. For this reason, it may help to try 1/2 mg or 1/4 mg at
night if the full 1 mg dose does not help at first. It is safe to increase the dose up to 10 mg if
needed. Try the same dose every night for 1-2 weeks, and see how it works. It is important to
take melatonin at least 60-90 minutes before going to bed, and 7-8 hours before you plan to wake
up.1-3,5, 15

Improving and Maintaining

Healthy Sleep Habits 5
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
 Over-the-Counter Medications, Supplements, and Foods to Help with Sleep
Chamomile has a soothing/calming effect. Drinking other warm, soothing
Chamomile Tea beverages and teas may work similarly. Do not drink too much, or you may
wake up to go to the bathroom.
These two are present in the nervous system and have a soothing or calming
effect on the mind. It can take time to raise levels after eating. Eat at least
one hour before bedtime, or earlier, to avoid possible heartburn and prevent
Foods Rich in weight gain.
Tryptophan and • Foods high in tryptophan: eggs (the whites), cod, soy, dairy products,
Melatonin poultry, bananas, sesame and sunflower seeds, whole grain cereals.
Foods high in melatonin: cherries, meats, bananas, rice, whole
grains/cereals, plums, oranges, apples, tomatoes, cucumbers, cabbage,
almonds, walnuts, sunflower seeds, mustard seed, fennel.
This is an important ingredient of serotonin, a chemical in the brain that helps
5HTP regulate mood. There is not a lot of research about how effective this is, but
(5-Hydroxy many people feel it is helpful, and it has few side effects. Talk with your
Tryptophan) healthcare professional about taking this (and about possible side effects) if
you also take other antidepressant or anti-anxiety medications.
Lavender or Place a few drops of essential oil on a cloth under your pillow or on your
Sweet Almond temples (if you do not have a skin allergy to essential oils). Inhaling the
Essential Oils aroma can make you sleepy.
This common electrolyte/salt can have a calming effect on the mind and
body. It can be taken as a supplement (a standard dose is 250 mg daily),
absorbed in an Epsom salt bath soaks, or eaten in magnesium-rich foods.
Magnesium
These include almonds, spinach, cashews, peanuts, black beans, soybeans
(soy milk, edamame, and tofu), yogurt, potatoes, and avocados. If it loosens
your stools too much, cut back on the dose.
A common starting dose is 0.25 mg to 3 mg.
• The regular/immediate release form works over 1-3 hours, and helps
Melatonin people get to sleep.
(Regular or • The extended release form slowly allows the melatonin to be digested
Extended Release) over time, helping people stay asleep.
Take either form 60-90 minutes before going to bed, and 7-8 hours before
you plan to wake up.
Take 400-900 mg 30 minutes—2 hours before bedtime. Valerian works best
if used every night for 4-6 weeks. It does not work as well on an “as needed”
Valerian Root
basis. Slowly taper off since withdrawal symptoms can occur (this is very
rare).
Diphenhydramine
(Examples: It only works for 3-4 days and then becomes ineffective. Should not be used
Benadryl, Tylenol by older adults.16 Increases risk of developing dementia later in life.17
PM)

Improving and Maintaining

Healthy Sleep Habits 9
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
Prescription medications to help with sleep are listed below. Note that many of these have side
effects and are not the best options for improving sleep in the long term.

Prescription Medicines to Help with Sleep 1,5,6,15

Amitriptyline can be useful if a person also has pain symptoms and
Amitriptyline (Elavil) frequent headaches. It can cause several side effects: dry mouth,
10-100 mg at bedtime blurry vision, constipation, and low blood pressure after just standing
up.
Eszopiclone is longer acting than Zolpidem (Ambien) and Zaleplon
Eszopiclone (Lunesta)
(Sonata), so it can help if someone has trouble staying asleep. It can
1-3 mg at bedtime
interfere with deep REM sleep
This medication can be useful if a person also has depression. Low
Mirtazapine (Remeron) doses help with sleep, higher doses lose that effect but help more with
15-45 mg at bedtime depression. It does not cause problems with deep REM sleep like
other sedating antidepressants. It can cause weight gain.
This medicine works inside the brain, in a similar way to melatonin. It
Ramelteon (Rozerem) connects with the brain’s melatonin “receptor cells” to help the body
8 mg at bedtime feel tired. Its effects are likely no better than over-the-counter
melatonin for most people.
Trazodone can be useful if a person also has anxiety or depression,
Trazodone (Desyrel) since it also treats these conditions. It can also slow down or stop the
25-50 mg at bedtime brain from using its own serotonin and melatonin, however. It may be
best used with a melatonin supplement.
Zaleplon (Sonata) This medication is similar to Zolpidem but works more quickly. It would
5-10 mg at bedtime be most helpful for people with trouble falling asleep.
This is the most effective sleep medicine, although research shows it
increases sleep time only by an average of 7 minutes per night. It has
several side effects: it is habit-forming, can cause sleepwalking and
Zolpidem (Ambien) sleep-eating in a small number of people, and can interfere with deep
5-10 mg at bedtime rapid eye movement (REM) sleep. There are two forms:
• regular (immediate release) and
• extended release.
Take it at least 8 hours before you plan to wake up.
Benzodiazepines:
• Temazepam
(Restoril)
7.5-30 mg at bedtime These medicines are sedating and can work as sleep aids. They have
• Lorazepam (Ativan) side effects, including memory trouble and daytime fatigue. They can
0.25-1 mg at bedtime also cause more insomnia when the medicine wears off (called
• Clonazepam “rebound insomnia”). They can interfere with deep REM sleep. They
(Klonopin) 0.25-1 mg can also be addicting. They are not a good first choice.
at bedtime
• Alprazolam (Xanax)
0.25-1 mg at bedtime

Improving and Maintaining

Healthy Sleep Habits 10
PATIENT HANDOUT
University of Wisconsin Integrative Health
www.fammed.wisc.edu/integrative
 Rapid Eye Movement: REM Sleep
• REM sleep is correlated with better health,
decision-making, etc.
• “NREM sleep helps transfer and make safe
newly learned information into long-term
storage sites of the brain.”
• We typically go through 4 or 5 cycles of Wake
to REM to 4 stages of NREM each night. P.43
Tim’s Sleep on Nov4-5 by Sleep Cycle App

• Awake>REM>4 stages of NREM

Use of Rapid Eye Movement sleep
• “Two features define human beings relative to
other primates, both shaped by the hand of
sleep and our intense use of REM sleep
relative to other mammals:
• 1) our degree of sociocultural complexity and
• 2) our cognitive intelligence.
• REM sleep, and the the act of dreaming itself,
lubricates both of these human traits”
The TREE TO GROUND re-engineering
• If you accept for a moment that we evolved
from monkeys, you might understand that
sleeping in trees is not ideal. You are always at
risk of falling and hurting yourself.
• Shifting to the ground, and better still to a
cave would offer more safety. Walker suggests
that this change gave us the advantage of
better sleep which allowed our brains to grow
bigger and better over time.
 Siesta Cultures
Biphasic Sleep Patterns
• …few of us enjoy a full afternoon nap, further
contributing to our state of sleep bankruptcy. p.
69
• (Harvard Study in Greece): …”those that
abandoned regular siestas went on to suffer a 37
percent increased risk of death from heart
disease across a six-year period, relative to those
who maintained regular daytime naps.” p. 71
• Take a 30-minute nap after lunch or mid
afternoon.
 Naps
• P.115 Sleep is constantly modifying the
information architecture of the brain at night.
Even day time naps as short as twenty
minutes can offer a memory consolidation
advantage, so long as they contain enough
NREM sleep.
 Bright Light Effects/Circadian Rythm
• While in the morning, a bright sun can get us
going naturally, artificial light at night can
damage the natural circadian twenty-four
hour rhythm (bright lights at night) and keep
us from sleep.
12 Tips from Walker for Healthy Sleep:
Tip One
1. Stick to a sleep schedule. Go to bed and wake up
a the same time each day. As creatures of habit,
people have a hard time adjusting to changes in
sleep patterns. Sleeping later on weekends won’t
fully make up for a lack of sleep during the week
and will make it harder to wake up early on Monday
morning. Set an alarm for bedtime. Often we set an
alarm for when it’s time to wake up but fail to do so
for when it’s time to go to sleep. If there is only one
piece of advice you remember and take from these
twelve tips, this should be it.
 Tip Two
• Exercise is great, but not too late in
the day. Try to exercise at least thirty
minutes on most days but not later
than two to three hours before your
bedtime.
 Tip Three
• Avoid caffeine and nicotine. Coffee, colas, certain
teas, and chocolate contain the stimulant
caffeine, and its effects can take as long as eight
hours to wear off fully. Therefore, a cup of coffee
in the late afternoon can make it hard for you to
fall asleep at night. Nicotine is also a stimulant,
often causing smokers to sleep only very lightly.
In addition, smokers often wake up too early in
the morning because of nicotine withdrawal.
 Tip Four
• Avoid alcoholic drinks before bed. Having a
nightcap or alcoholic beverage before sleep
may help you relax, but heavy use robs you of
REM sleep, keeping in the lighter stages of
sleep. Heavy alcohol ingestion also may
contribute to impairment in breathing at
night. You also tend to wake up in the middle
of the night when the effects of the alcohol
have worn off.
 Tip Five
• Avoid large meals and beverages late at night.
A light snack is okay, but a large mean can
cause indigestion, which interferes with sleep.
Drinking too many fluids at night can cause
frequent awakenings to urinate.
 Tip Six
• If possible avoid medicines that delay or disrupt
your sleep. Some commonly prescribed heart,
blood pressure, or asthma medications, as well as
some over-the-counter and herbal remedies for
coughs, colds, or allergies, can disrupt sleep
patterns. If you have trouble sleeping talk to your
health care provider or pharmacist to see
whether any drugs you are taking might be
contributing to your insomnia and ask whether
they can be taken at other times during the day
or early in the evening.
 Tip 7, 8, & 9
7. Don’t take naps after 3 pm. Naps can help make up
for lost sleep, but late afternoon naps can make it
harder to fall asleep at night.

8. Relax before bed. Don’t overschedule your day so that

no time is left for unwinding. A relaxing activity, such as
reading or listening to music, should be part of your
bedtime ritual.

9. Take a hot bath before bed (ofuro!). The drop in body

temperature after getting out of the bath may help you
feel sleepy, and the bath can help you relax and slow
down so you’re more ready to sleep.
 Tip 10
• 10. Dark bedroom, cool bedroom, gadget-free
bedroom. Get rid of anything in your bedroom
that might distract you from sleep, such as
noises, bright lights, an uncomfortable bed, or
warm temperatures . You sleep better if the
temperature in the room is kept on the cool side.
A TV, cellphone, or computer in the bedroom can
be a distraction and deprive you of needed sleep.
Having a comfortable mattress and pillow can
help promote a good night’s sleep. Individuals
who have insomnia often watch the clock. Turn
the clock’s face out of view so you don’t worry
about the time while trying to fall asleep.
 Tip 11
• Have the right sunlight exposure. Daylight is
key to regulating daily sleep patterns. Try to
get outside in natural sunlight for at least
thirty minutes each day. If possible, wake up
with the sun or use very bright lights in the
morning. Sleep experts recommend that, if
you have problems falling asleep, you should
get an hour of exposure to morning sunlight
and turn down the lights before bedtime.
 Tip 12
• Don’t lie in bed awake. If you find yourself still
awake after staying in bed for more than
twenty minutes or if you are starting to feel
anxious or worried, get up and do some
relaxing activity until you feel sleepy. The
anxiety of not being able to sleep can make it
harder to fall asleep.
 Sleep Advice
https://time.com/5866724/sleep-tips-andre-iguodala-cheri-
mah/?utm_source=newsletter&utm_medium=email&utm_campaign=the-brief-pm&utm_content=20200715&et_rid=31583510

Andre Iguadala (NBA - BB star) suggests

1. No TV, No cell-phone – turn off,--

2. Cool sheets, temp down, --
3. Comfortable Pajamas –
Start at 7:40 -- sleep
What are the top 3 ways to get better
sleep? (advised by Dr. Cheri Mah)
1. Calm down (10-20 minutes) before going to bed,
think calmly and go to sleep. (meditate)
have a Wind-down ROUTINE
2. Physical – Dark, cave Sound-quiet sounds,
white noise machine 15-19.5 cel. (TM-Relax App.
ocean waves, rivers, and birds.)
3. Do it as a team – Next breakout Room person call
them up tonight and ask them how they will go to
sleep well. (Tim shares sleep data with a friend each
day – if you know you are going to share, you tend
to want to do better.)