Sleep Smarter: 21 Essential Strategies to Sleep Your Way to a Better Body, Better Health, and Bigger SuccessStevenson and Gottfried

Join the host of America’s most popular health podcast, and its most famous women’s hormone expert, in learning good sleep strategies. Stevenson not only brought himself back from degenerative bone disease with better nutrition and sleep, he has achieved impressive business and fitness goals with his excellent health. His sleep makeover takes you through nutrition for sleep, circadian hacking, stress reduction, fitness tips, and so much more.

SLEEP specialty page | Engage Psychiatric, San Francisco and Pasadena

Some clients come to see me specifically to work on their sleep

 

The one traveling the farthest came from Sweden; another from Mexico. But well over 90% of the people I see for mood, anxiety, trauma, or ADHD also complain of insomnia, unsatisfying sleep, or daytime sleepiness.

Cara Hoepner, Engage Psychiatric | evidence-based, client-centered, well beyond well
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I work with clients to get them sleeping well again, sometimes for the first time since they were a kid, by asking questions about root cause, and using the methods of their choice to correct unsatisfying sleep and hypersomnia, safely.

Rapid eye movement (REM) sleep is where we have most of our dreams – even those who do not remember dreams do have them.


The REM phase is also known as paradoxical sleep and sometimes desynchronized sleep because of physiological similarities to waking states, including rapid, low-voltage desynchronized brain waves.
 

What is Sleep? And How Much Do I Need?

 

During sleep neurochemicals adjust such that consciousness is altered and we interact little with our surroundings, sensory activity is relatively inhibited, and during REM sleep there is reduced muscle activity and inhibition of nearly all voluntary muscles, to keep us from acting out during dreams. Dreams occur chiefly during REM sleep

Sleep Stage Transitions | Cara Hoepner, Integrative Psychiatry

Sleep Occurs in Stages

Sleep is organized into 4–6 nightly cycles comprised of REM and NREM (non-rem, stages N1–N3), with a typical duration between 90 and 110 minutes per cycle.
 

N1 occurs first, just after you fall asleep, lasts less 1–7 minutes, and is considered “light” sleep. The transitional state between wake and sleep is called hypnagogia, and some people (including teens and narcoleptics) experience involuntary, imagined hallucinations, such as being pursued and unable to move, “hypnagogic hallucinations”.
 

 

  • REM is 20–25% of a healthy night’s sleep
     

  • REM first occurs approximately 90–110 minutes into sleep, the first REM period is only around 10 minutes, and REM cycles lengthen and occur more frequently on the back half of the night
     

  • Those who enter REM earlier than 100 minutes after sleep onset (reduced REM latency) may have

    • Depression
       

    • "REM pressure” or rebound (a consequence of REM deprivation, in people who skip out on a full night’s sleep), or they may be
       
    • Withdrawing from drugs or supplements that suppress REM
       

    • Sleep onset REM periods (SOREMPs) occurring only 15 minutes after sleep onset signal narcolepsy
       

  • REM is important for heart health, heart rate variability, emotional rehearsal (your amygdalae are 30% more active in REM than in waking life), and learning – the consolidation of implicit (nondeclarative) memories
     

  • When rats are deprived of REM sleep for around 12 days, they die.

N2 is where you spend 50% of your night. This stage is deeper than N1 but lighter than N3 slow wave sleep.
 

  • N2 is filled with K complexes and sleep spindles. K-complexes transfer information to the thalamus, which then communicates with the cortex during sleep. This synchronization produces sleep oscillations such as spindles and delta waves
     

  • Sleep spindles occur largely in N2; they allow explicit memories to be consolidated. Some believe sleep spindles also act as a distraction from the environment so we are not awakened. They can be seen on EEG monitoring in the sleep lab
     

Slow wave sleep, N3, makes up 20% of a good night’s sleep.
 

  • In SWS explicit memories are consolidated, and the body repairs. Inflammation is addressed by the immune system
     

  • The glymphatic system – a collaboration between the immune system and the lymphatic system, occurring only in the brain – opens to flush the day’s metabolic processes and debris, including amyloid beta, implicated in formation of Alzheimer’s dementia

Stanford Sleep Clinic's Dr. Rachel Manber – Sleeping Well as We Age

Sleep Changes As We Age

As we age, the suprachiasmatic nucleus (SCN), which sets our daily circadian rhythms, deteriorates, and we may feel tired or alert at different times of the day than we used to.
 

  • The elderly often have insufficient exposure to daylight, which complicates this effect
     

  • Circadian regulation changes make sudden changes to sleep schedules – such as jet lag, or daylight savings time – more difficult to adjust to
     

Depression, anxiety, heart disease, diabetes, and pain may disrupt sleep quality and duration as we age, and drugs that older people may take to maintain these conditions may have an effect on sleep quality and stages.
 

Retirement or shorter sleep times at night may lead to additional napping (25% of older adults nap), and a less structured sleep routine, if the naps are extended (>25 minutes or so) and if they are in the late afternoon.

As we age, we “phase advance”, getting to sleep earlier and rising earlier, and there are other changes to the circadian cycle.

Older people may wake at night if they need to urinate, but also due to changes in sleep architecture: Older adults spend more time in lighter stages of sleep (N2, REM) and less time in N3, slow wave sleep. REM tends to remain stable.

These shifts may contribute to older people waking up more often during the night and having more fragmented, less restful sleep.

Sleep Disorders in Older Adults – Medlineplus.com

 
 
 

Consequences of Poor or Inadequate Sleep

Inadequate or poor quality sleep can come from
 

  • Spending too little time in bed, with intent to sleep
     

  • Poor sleep efficiency from frequent awakenings, a medical illness, or a sleep disorder (see below)
     

  • Inadequate REM or slow wave sleep due to pharmaceuticals, going to bed at a time not aligned with your chronotype, or inconsistent bed and wake times

How lack of sleep affects health, and tips for a good night's rest – Matthew Walker

Some consequences include:

  • Depression/mood disorders, anxiety, and cognitive complaints
     

  • Type II Diabetes (up to Up to 83% have unrecognized obstructive apnea)
     

  • Risk for high blood pressure, heart disease, atrial fibrillation, congestive heart failure, and stroke (3x risk if apneic)
     

  • Diminished memory, alertness, learning capacity
     

  • Risk for dementia – those with apnea live with mild cognitive impairment 10 years earlier
     

  • Cancers (the World Health Organization names shift work as a probably cause)
     

  • Bone density issues
     

  • Sexual dysfunction (69% of men with apnea have erectile dysfunction)
     

  • Weight gain and obesity
     

  • Increased sensitivity to pain
     

  • Up to 7 Years’ decreased life expectancy (let alone quality)
     

  • Fatigue and daytime sleepiness
     

  • Poor school & work performance
     

  • Increased risk of auto & workplace injury

What Are Sleep Disorders?

The most common sleep disorder is insomnia.

Other sleep-wake disorders include those in this illustration.

In my practice I most often see insomnia in many presentations, apnea, RLS/PLMS, and sleep phase delay, or “night owls”.

Insomnia

Some people have difficulty falling asleep – initial insomnia.

Others have trouble staying asleep – waking sometimes multiple times per night – middle insomnia.

Others wake at 4 or 5 AM and cannot resume sleep – terminal insomnia.

What are the Different Types of Insomnia and Their Symptoms? Sleepopolis has answers

 

Some of the reasons for insomnia might be the following – looking for root cause informs treatment:

Norepinephrine: this neurochemical drives initial insomnia from anxiety, and also from having a “busy brain” in the evening. Anxiety can also drive middle insomnia.

 

Psychostimulants such amphetamine and methylphenidate, and methylxanthines (theobromine, theophylline, caffeine) – these are chemicals found in foods such as coffee, tea, maca, and chocolate.

Caffeine has a 12 hr quarter life.

 

Physical conditions:

 

  • Low cortisol: if your body has too little cortisol, you cannot conduct gluconeogenesis (making glucose from proteins) overnight, and the locus coeruleus will produce norepinephrine as a result of your hypoglycemia, waking you up, often with a racing heart

 

  • High cortisol: cortisol expresses, for those with a normal chronotype (bedtime earlier than around midnight), at 4 AM, and peaks around 6 AM. If you wake at 4 or later and can’t get back to sleep, cortisol may be spiking from anxiety, melancholic depression, or a physical illness such as hyperthyroidism

 

  • Histamine intolerance, mast cell activation syndrome, mycotoxin exposure (from mold in your home or office) have all caused middle and terminal insomnia for my clients

 

  • Nocturnal cardiac arrhythmias cause awakenings

 

  • Perimenopause and menopause: some women will have night sweats from inconsistent estrogen levels, their sleep will lack quality from too little progesterone, and they may find themselves fully awake at 3 AM some nights

 

Wrong place, wrong time:

 

  • Circadian rhythm disorders: those with an evening chronotype may think they have insomnia if they are unable to go to bed much earlier than their natural bedtime

 

  • Lack of a regulated sleep-wake cycle

 

  • Pattern matching (stimulus control) – if your body learns that the bed is for work and television rather than sleep and sex, it may not want to sleep there. See sleep hygiene, and Cognitive Behavioral Therapy of Insomnia, below.

 

Psychological factors: I have clients who have experienced trauma, and they perceive sleep to be a lack of ability to be vigilant, sleep equals vulnerability.

 

There are safe pharmacologic, behavioral, or root cause solutions to each of these problems.

Sleep apnea is a serious condition that occurs when a person’s breathing is interrupted during sleep. The airway closes (apnea) or partially closes (hypopnea), and people with untreated sleep apnea stop breathing repeatedly — often hundreds of times per night.

 

Apnea is obstructive or central:

  • Obstructive sleep apnea/hypopnea is caused by the relaxation of your throat muscles during sleep

  • Central sleep apnea/hypopnea is caused by your brain failing to send signals to the muscles that allow you to breathe

 

For those with sleep apnea, cells in the brain — and the rest of the body — may not be getting the oxygen they need to do their job.

42 Million American adults are estimated to have some form of sleep apnea

1 in 5 people in the United States may suffer from OSA (obstructive sleep apnea)

70–80% of the people with the most serious cases of sleep apnea are undiagnosed

1:1 After menopause, women are just as likely to have sleep apnea as men

Consequences of apnea

 

All of the consequences of poor or inadequate sleep listed above are casualties of untreated apnea.

 

Apnea is extremely common:

  • 25% of middle-aged adult men have sleep apnea

How is apnea treated?

Medical interventions

  • Continuous positive airway pressure therapy, CPAP – also available as alternating and biphasic options (APAP and BiPAP)
     

  • Removal of the obstruction or other surgery if applicable
     

  • A mechanism for your mouth that makes the airway larger or more stable

 

 

Lifestyle alterations

  • Losing weight
     

  • Consuming a healthy, anti-inflammatory diet
     

  • Giving up smoking
     

  • Avoiding sleep medications or sedative medication

  • Drinking less alcohol or stopping completely

  • Changing your sleep position

 

If your hypopnea is mild, then lifestyle changes may be the only treatment necessary.

Restless Legs Syndrome, and Periodic Limb Movements of Sleep

Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a condition that causes uncontrollable urges to move the legs, usually because of uncomfortable sensations

  • RLS can happen at any time of day, be worse if sitting or lying, and typically is worse or only present in the evening or nighttime hours
     

  • It affects legs chiefly, but sometimes the arms as well
     

  • Sensations include aching, pulling, throbbing, itching, crawling sensation, or a feeling of electricity
     

  • Moving temporarily relieves the discomfort
     

  • RLS is disruptive of sleep efficiency and quality, causing sleep fragmentation
     

  • RLS can begin at any age (many children with ADHD endorse it) and it generally worsens with age, as the dopamine system changes with time
     

  • RLS is thought to be caused by poor dopamine neurotransmission, but sometimes has no known cause
     

  • RLS can be hereditary (especially when occurring under the age of 40), occurs in 25% of pregnant women due to hormonal changes, is more common in women than men, and is very common in those living with ADHD
     

  • RLS is often comorbid to (comes along with) peripheral neuropathy, kidney failure, spinal cord conditions, and iron deficiency – Iron supports the dopamine system

 

Periodic limb movements of sleep (PLMS )is a similar condition, which occurs only while lying in bed at night, and without the uncomfortable sensations and urges – those living with PLMS tend to twitch and kick involuntarily as they lie in bed initiating sleep, and often throughout the night. Treatments that work for RLS will often work for PLMS as well, as deficits in neurotransmission are common in each.

 

Treatment

Lifestyle changes, self-care tips, and medicines can help people who have RLS or PLMS.

Josh Axe has an excellent webpage on natural treatment of RLS, and a video as well

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Spotlight on ADHD

I encourage all individuals experiencing RLS to be evaluated for ADHD, and all clients living with ADHD to have a sleep study.

 

I offer hassle-free, inexpensive, data-rich at-home sleep studies through my partnership with Itamar, with integrated interpretation and evaluation by two of San Francisco’s finest sleep medicine specialists

 
 

When Sleep is not Restful

Some of my clients feel their sleep is “light” or fussy, and sometimes it has been since they were very young. Their total sleep time/efficiency may be poor, or they may have altered sleep architecture. Causes have been the same as those mentioned above for insomnia, and additionally.

Engage Psychiatric, San Francisco and Pasadena

Perceived poor sleep Brederoo et al

Engage Psychiatric, San Francisco and Pasadena

Disturbances of Circadian Rhythm

Circadian rhythm disorders include alterations from the normal circadian clock, which in humans is close to 25 hours, when isolated from stimuli like daylight and timekeeping. Most people naturally feel tired and ready for bed between 10 PM and midnight, but there are a few individuals who have a

  • Sleep phase advance – they become tired very early, and then wake in the wee hours of the morning, unable to sleep further, and
     

  • Many individuals – including my clients with ADHD – have a sleep phase delay, with a natural bedtime of 1–2 AM. Their sleep is less restful, and they may have what they believe to be initial insomnia, if they attempt to force a 10 PM bedtime, to get up at 6 and be ready for their workday
     

  • An uncommon disorder – usually only present in the blind, but sometimes in sighted individuals – is the non-24-hour sleep-wake disorder, a condition in which a person's day length is significantly longer than 24 hours, so that sleep times get later each day, cycling around the clock in a matter of days or weeks. People with non-24 will find themselves having periodic, episodic insomnia for a few days, and attacks of extreme daytime fatigue for several days during other periods.

Sleep phase delay is seen daily in my practice.

 
 

  • Hypervigilance
     

  • Sleep apnea, or simply snoring
     

  • Periodic limb movements of sleep and restless legs syndrome, innate or caused by medications
     

  • Altered sleep architecture, with little REM or slow wave sleep as seen on a monitor, or much sleep fragmentation
     

  • Nocturnal seizures
     

  • Drugs, such as beta blockers, alpha agonists, some antihistamines, steroids, and others
     

Treatment is specific to the root cause, if it is apparent, or medicines that improve sleep depth, efficiency, and total sleep time, such as baclofen, gabapentin, and pregabalin.

Hypersomnia, or Fatigue

Hypersomnia and fatigue may be caused by a sleep disorder, but it is as common that it has a unique etiology. Take a questionnaire to see if you suffer from excessive daytime sleepiness, and see below for the many possible reasons individuals live with hypersomnia or fatigue.

 

Treatments are many, as they are specific to the root cause.

Several of the possible causes below are covered on my baseline laboratory panel*, or can be added.

  • Sleep disorder (insomnia, apnea, narcolepsy, RLS, PLMS, other)
     

  • Iron-deficiency anemia, high ferritin levels, other hematologic disorder (e.g., thalassemia)*
     

  • Hypothyroidism, hyperthyroidism*
     

  • Congestive heart failure
     

  • Respiratory disease (causing hypoperfusion)
     

  • Gut dysbiosis, leaky gut, poor diet/nutrition, food allergies
     

  • Systemic inflammation (e.g. high homocysteine* and hsCRP*), which may be caused by methylation issues, infections, gingivitis, high BMI, other reasons
     

  • History of traumatic brain injury
     

  • Occult (stealth) infections*: human herpes virus 6 (HHV6), mycoplasma pneumoniae (cytomegalovirus, or CMV, mononucleosis reactivation), Epstein Barr (EBV, mononucleosis reactivation)
     

  • Lupus or multiple sclerosis, autoimmune diseases (I test for Hashimoto’s thyroiditis)*
     

  • Lyme disease or mycotoxin exposure (from mold at home or work)*
     

  • Low RBC magnesium stores*
     

  • Serum copper excess (in relation to zinc)*

How are Sleep Troubles Treated?

 

Monitoring and Evaluation

 

With WatchPAT One

  • Itamar will ship your disposable unit – covered by most insurance, $300.00 max without insurance
     

  • They will train you virtually
     

  • You conduct a one-night study at home, and dispose of the device
     

  • Data is automatically transmitted via a phone app, and your data is automatically transmitted to my portal

Sleep monitoring allows opportunity for insight into sleep disorders.

With sleep monitoring, you can see how

  • Meal size
     

  • Composition, and timing
     

  • Bedtime and wake time
     

  • Room or bed temperature
     

  • Medicines and supplements

… and more

 

affect your sleep architecture and efficiency overnight, as well as heart rate and variability, breath rate, and body temperature, depending on the monitor you choose.

I have an Oura ring, as do many of my clients, and we have run many experiments and shaped new habits with its objective reports.

  • The Oura ring and Fitbit Ionic were the two devices found to have reasonable accuracy in a recent clinical trial. Note that they do not compare with polysomnography from a sleep study, they do not have absolute accuracy – but they do have relative accuracy. Within their own dataset, you can see how your habit changes contribute to your sleep quality.

Monitoring Parameter
Oura Ring
Fitbit Ionic
Time asleep and efficiency
Sleep stages (REM, light and deep sleep, awake)
Sleep score
Heart rate
Breath rate
Change in body temperature
Oxygen variation, which can help to uncover apnea

At-Home Sleep Study with WatchPAT One

 

In-home testing all in as little as a week –

 

The first at-home sleep study to:

  • Feature a sleep architecture report

  • Be disposable – no waiting for a unit to become available, or returning the unit to the lab

 

For many years my clients waited 4 months for a sleep study at an excellent center, they visited the hospital for an interview with the doctor, then had their study in lab or at home, returned the equipment if necessary, then back to the doc for their interpretation. This was time-consuming, many steps, and often expensive.

  • Itamar will connect you with an expert sleep specialist of my choosing for evaluation and any prescriptions, over video visit
     

  • See sample report, and publications

Difference between WatchPAT One and a night in the sleep lab:
 

  • More comfort
     

  • More convenience, streamlined process
     

  • No wait time
     

  • Little expense – WatchPAT One is covered by commercial, Medicare, and Tricare insurance
     

  • Availability (some insurers require an at-home test)

 

A night in the lab, however, includes EEG data (which can indicate nocturnal seizures) and this home study does not.

 
Natural Remedies for Insomnia | Engage Psychiatric, San Francisco and Pasadena

Medications and Natural Remedies

 

There are around 30 medications available to me with which to treat insomnia and nudge sleep architecture; there are also a selection of herbs and amino acids, and magnesium, all of which may work well when the insomnia is mild-to-moderate.

 

When choosing a medicine for sleep, I pay attention to:
 

  • Whether that drug may treat initial, middle, or terminal insomnia
     

  • Whether it will help a busy brain to calm in the evening and drift into sleep
     

  • Whether my client needs more slow wave (deep) sleep
     

  • Whether they desire more consolidation, efficiency – more restful sleep

 

I am careful to attempt to elicit root cause of the insomnia before prescribing, as it is preferable to solve the problem from the bottom up than to take a top-down approach with a drug.
 

Sleep medicines and natural treatments:
 

  • There are a number of agents that are safe to use as long as the client doesn’t have untreated sleep apnea, and these include trazodone, gabapentin, baclofen, clonidine, and the orexin antagonists Belsomra and Dayvigo, which turn off the wakefulness promoting chemical orexin. Several of these medicines will worsen apnea (episodes where the airway closes) if CPAP or similarly effective treatment is not being used
     

  • Commonly used natural agents for sleep, alone or in combination, include cannabidiol, melatonin, magnesium, passion flower, hops, valerian, lemon balm, chamomile, holy basil, Chinese skull cap, lactium, GABA, taurine, glycine, L-theanine, L-arginine, and adenosine. They can be purchased alone or in combination, and some have human data on their efficacy in insomnia.

 

Sleeping pills may have significant risks, which we work to avoid:
 

  • I steer clear of Z drugs [Ambien (zolpidem), Sonata (zaleplon), Lunesta (eszopiclone)), also known as “omega ones” as they bind to the omega 1 benzodiazepine receptor, as they are a risk for Alzheimer’s dementia, and just 18 pills per year for 2.5 years increases your risk for cancer 35%.
     

  • Benzodiazepines such as Klonopin (clonazepam), Xanax (alprazolam), and Ativan (lorazepam) have many risks

How is Sleep Treated with Behavioral Therapy?

Sleep Hygiene Tips | Cara Hoepner, Integrative Psychiatry

Sleep is driven by circadian rhythm (Process C) and homeostasis, the buildup of adenosine (Process S).

 

Sleep hygiene capitalizes on these drives and more:

  • Practices that improve circadian rhythm (Process C), such as the timing of food, wake time, and light
     

  • Those that improve homeostasis, the buildup of adenosine throughout the day (Process S), such as avoiding methylxanthines (caffeine, theophylline, theobromine), and not taking daytime naps that are late or lengthy
     

  • Practices that take advantage of the human as habit-buildling, pattern-matching machine, such as only using the bed for sleep and sex (to avoid association with waketime activities)
     

  • Other practices – for instance, a hot bath to lower core body temperature around 90 minutes later. Keeping the bedroom cool. Covering the alarm clock so it’s not visible. Meditation, relaxation, or bedtime stories. Avoiding heavy or spicy foods and alcohol near bedtime.

Cognitive Behavioral Therapy of Insomnia – CBTi

CBTi is effective in around 80% of people who try it – likely most anyone whose insomnia is not complicated by medical illness, or a trauma history that causes them equate sleep with vulnerability. It has been effective for every referral I have made.

CBTi has two components:

 

Stimulus Response, also known as the Bootzin Method, after Richard Bootzin who developed it in 1972, has 5 sleep hygiene elements, each of which strengthens circadian rhythm or a person’s associations between their bedroom and sleep
 

  • Go to bed only when sleepy (i.e., falling asleep)
     

  • Get out of bed when unable to sleep (do something relaxing in another room until able to sleep)
     

  • Get out of bed at a consistent time each morning (wake time strengthens circadian rhythm)
     

  • Use the bed and bedroom only for sleep and sex
     

  • Do not take daytime naps – rest in ways less likely to lead to dozing (i.e., not supine)

 

Sleep restriction – progressive restriction of sleep, no less than 5 hours of sleep per night, is brought into the therapy when the client is ready, and it capitalizes on homeostasis, helping adenosine to build, and the client to learn what “sleepy” feels like, and to initiate sleep on their own.

There are usually 6 sessions, if doing this with a therapist, and there is a time during the sessions at which sleeping pills are tapered.

 

You may do CBTi with a therapist or with an app, or an online program.

 

THERAPISTS

I know therapists who hold individual and group treatments, in person or over video. Ask me who I am working with currently.

ELECTRONIC OPTIONS

  • CBT-i Coach app can be your companion through the process, or it can be your total CBTi solution if you are very disciplined
     

  • Insomnia Coach is helpful also –
     

Both apps were developed by the US Dept of Veterans Affairs, to help vets living with mental health challenges

  • Finally there is Sleepio, another CBTi app that I like

 

Lifestyle Matters –

Just as with any other condition involving mood and anxiety symptoms, clients are encouraged to treat their bodies well, doing as many of the following as suits them. According to the CDC, only 6% of Americans have a healthy body mass index (BMI), sleep adequately, drink alcohol moderately or not at all, exercise adequately, and are never smoking. And only 12% of American adults are metabolically healthy! Here are some possible goals:

1 Exercise – aiming for half hour five times weekly. If regular walking is what suits you, this is largely what our ancestors did.

Emily Deans – What Not to Eat for Good Mental Health

2 A healthful diet is important to good sleep.

 

  • Deficiency in magnesium, calcium, and vitamins A, C, E, D, and K can lead to problems with sleep. Other nutrients include potassium, vitamin B6 and other B vitamins, folic acid, zinc, and copper.

 

  • High blood sugar and high-carbohydrate meals can increase nighttime awakenings and decrease deep sleep, while Mediterranean diet improves sleep quality, and it includes omega 3 fatty acids, which also are associated with healthy sleep. So is does the DASH diet. which is designed to reduce hypertension.
     

  • A healthful, anti-inflammatory diet that is well-rounded will promote the body’s ability to make melatonin, GABA, serotonin, and acetylcholine, all of which are needed for a good night’s rest.
     

  • The nutrients listed above are on my baseline lab set, and I have protocols written for repletion with quality supplements should you need them.
     

Listen to Emily Deans and Chris Kresser discuss ancestral diet and psychiatry.

3 Limit alcohol use, or you may find yourself waking in the middle of the night, and with reduced REM sleep. Drinking should end at least 3 hours before bedtime.
 

  • The National Institute on Alcohol Abuse & Alcoholism (NIAAA) defines moderate drinking as up to four alcoholic drinks for men and three for women in any single day and a maximum of 14 drinks for men and seven drinks for women per week
     

  • A cardiologist or oncologist would have very different recommendations
     

  • Alcohol is not a sleep aid.

4 I would round this out with a meditation practice. There are many types (not just mindfulness), and each may change your brain differently. I practice Vedic meditation, 20 minutes twice daily. There are many teachers, including the Transcendental Meditation corporation, and Emily Fletcher in New York, my teacher. When I started, my sleep improved – with both slow wave sleep and REM increasing to around 28% each!

Guided meditation for sleep and anxiety, with Emily Fletcher

Breathwork can be excellent for sleep initiation – the 4-7-8 breath is an ancient Ayurvedic practice. Follow along with Dr. Weill. 

 
 

Why We Sleep: Unlocking the Power of Sleep and Dreams  – Matthew Walker

Neuroscientist and sleep guru Matthew Walker shows you the data and clinical examples that provide a 360 review of sleep and its impact on every aspect of health and daily life, from focus and mood to immunity and cardiovascular health – and dementia. Learn about why and how each of your daily habits affects sleep, what each stage of sleep does for you, long-term impact of common sleep aids, and more.

Sleep is your superpower | Matt Walker

The Book of Sleep: 75 Strategies to Relieve Insomnia – Nicole Moshfegh

This book is based in Cognitive Behavioral Therapy of Insomnia (CBTi), but in CBTi there are 5 basic sleep hygiene tips in the Bootzin Method. Moshfegh expands this to 75 tips that each independently can make a different in your sleep. Start anywhere you like in this book, and from your bedtime, to keeping cool, to kicking methylxanthines (e.g., caffeine) you will make improvements in your sleep quality.

Sleep Smarter Book Summary |  Shawn Stevenson

Sleep Smarter: 21 Essential Strategies to Sleep Your Way to a Better Body, Better Health, and Bigger SuccessStevenson and Gottfried

Join the host of America’s most popular health podcast, and its most famous women’s hormone expert, in learning good sleep strategies. Stevenson not only brought himself back from degenerative bone disease with better nutrition and sleep, he has achieved impressive business and fitness goals with his excellent health. His sleep makeover takes you through nutrition for sleep, circadian hacking, stress reduction, fitness tips, and so much more.

Change Your Schedule, Change Your Life: How to Harness the Power of Clock Genes to Lose Weight, Optimize Your Workout, and Finally Get a Good Night's Sleep

Kshirsagar and Seaton

Sleep is driven by Process S (homeostasis, adenosine) and Process C (circadian). Ever wonder just how much going to bed at your own correct bedtime, and keeping it regular, affects your health? Did you know that even “social jetlag” (sleeping in on weekends) affects mood? Learn about your circadian rhythm and follow the holistic 30-day plan to adjust your daily schedule (from your AM workouts to your bedtime snacks) for enhanced wellbeing.  

Quiet Your Mind and Get to Sleep: Solutions to Insomnia for Those with Depression, Anxiety, or Chronic PainCarney and Manber

A book on Cognitive Behavioral Therapy of Insomnia, specialized for those of us who live with comorbid conditions that complicate improvement. This book goes to the root cause of many persons’ insomnia,  and offers the same techniques used by experienced sleep specialists.

Five Steps to Sleep Well | Colleen Carney

Say Good Night to Insomnia: The Six-Week, Drug-Free Program Developed at Harvard Medical School

– Jacobs

Learn CBTi from a 20-year pioneer in the field of sleep. Jacobs' program, developed and tested at Harvard Medical School, has improved sleep long-term for 80% of his patients, making it the gold standard in behavioral therapy.